Health inspection·November 12, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some needed for diarrhea. Ordered 10/04/25.-Finasteride Oral Tablet 5 MG (Finasteride) Give 2 tablets by mouth one time a day for genitourinaryagents - miscellaneous (medication for bladder spasms). Ordered on 10/15/25.-Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth one time a day related to essential(primary) hypertension hold if SBP less than 110 or DBP 60 or hr 60. Ordered 10/05/25. Record review of Resident #1's MAR and TAR, dated 11/12/25, reflected Resident #1 was administered the following:-Imodium oral tablet 2 mg, give 1 tablet by mouth one time only for anti-diarrheal/probiotic agents until 10/08/2025 15:59[3:59 PM]. Imodium was administered on 10/08/25. -Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML (Enoxaparin Sodium) Inject 0.4 ml subcutaneously one time a day for DVY[T] (DVT is a blood clot that forms in the deep veins, most often in the legs) until 11/03/2025 15:00 [3:00 PM]. Resident #1 was administered daily enoxaparin sodium injections to prevent blood clots starting 10/04/25 through 10/21/25 at 08:00 AM. -Aspirin 81 mg was administered daily from 10/05/25 through 10/21/25 at 09:00 AM.-Lisinopril 10 mg was administered daily 10/04/25 through 10/21/25 at 09:00 AM. Blood pressures vitals were within acceptable reading above 110/60.-Finasteride Oral Tablet for benign prostatic was administered daily 10/04/25 through 10/21/25 at 09:00 AM.-cleanse open stage 2 wound to bottom with normal saline, pat dry and apply calcium alginate, coverwith dressing daily and PRN one time a day for pressure ulcer.-SHOWER days on TH-THU-SAT, during the 2-10 shift. one time a day every Tue, Thu, Sat for shower-Start Date- 10/04/2025 1600 were completed 10/4/25 through 10/18/25 at 4:00 PM.-2 Pillows under Right Heel 2hrs two times a day for edema -Start Date- 10/11/2025 1700 [5:00 PM] until 10/21/25.-Monitor Left knee Surgical incision every Shift. every shift for incision. Monitoring completed on [DATE]/4/25 through 10/21/25 in the morning.-May use air mattrass r/t pressure sore every shift for wound healing -Start Date- 10/20/2025 1500 [3:00 PM]-according to TAR entry 10/20/25 evening through 10/22/25 morning the number 06 was entered on MAR which indicated hospitalized /Not used. Record review of Resident #1's comprehensive care plan, initiated 10/20/25, reflected one care area was completed for Resident #1 during his admission to the facility with a focus: he had an actual fall due to poor balance, unsteady gait and generalized weakness. The goal was to resume usual activity without further incidents over next 90 days. The interventions were to encourage calling for assistance with ADLs. The comprehensive care plan did not include any other care areas and no focus areas, no goal and no interventions for stage 2 pressure ulcers, colitis, edema, use of a black box medication, use of blood pressure medication lisinopril, use of blood thinners, diarrhea due bowel complications, and benign prostatic urinary tract symptoms were completed. Record review of Resident #1's physical therapy assessment, completed 10/05/25 to 11/2/25, reflected Resident #1was referred to skilled therapy services after a recent hospital discharge of complications with diarrhea and post left knee replacement done on 09/15/25. Record review of summary of Daily skilled services for certified period of 10/05/25 to 11/2/25 did not reflect any barriers impacting treatment. Record review of Resident #1's progress note, dated 10/19/25, by RN A, reflected Resident axox2 skin warm and dry. Skilled care unilateral primary osteoarthritis, left knee, weakness. Up in wheelchair with mod assist. denies any pain. Encouraged PO fluids. assist to washroom for bowel. Uses urinal. On lovenox daily. No adverse reaction noted. Dressing changed done buttocks area. on PT,OT. call light within reach.During an interview with Resident #1's family on 11/12/25 at 9:47 AM revealed the facility had a care plan meeting on 10/09/25 addressing Resident #1's open pressure wound on his bottom, wheelchair lock mechanism dysfunction, lack of progress getting colitis diarrhea under control and asking for more Imodium (a medication used to slow or stop diarrhea), and concerns about wearing a diaper. Resident #1's family stated, nothing had been done to address concerns in their care plan meeting by discharge 10/21/25 and she had to stop at the nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 2 of 6 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 11/12/2025 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 station to ask for Imodium for Resident #1 which she was told unless the resident could show them the poop, they could not order it per facility policy. She stated due to the uncontrolled diarrhea, his bed sores had become irritated. Family stated Resident #1's pressure ulcer had opened due to not receiving proper hygiene care and not ordering a waffle mattress [air mattress] timely after the care plan meeting. Family stated on 10/21/25 Resident #1 was sent to the hospital and diagnosed with pulmonary embolism (blood clot that travels from veins to lungs), c-diff (this is a bacterium that can cause an intestinal infection leading to symptoms like diarrhea and colitis), and colitis. In an interview with RN A on 11/12/25 at 1:30 PM, revealed RN A stated he did not attend the care plan meeting, and he did not implement anything to the care plans. He said the admission nurse, ADON and DON oversaw the care plans. RN A said care plans were important to know how to care for the residents. He said failure would result in not having adequate care for the residents. In an interview with CNA C on 11/12/25 at 2:11 PM, She said nurses were responsible for the care plans and they would give CNA's report on how the residents ambulated, diet, any isolations etc. Interview with the SW on 11/12/25 at 2:39 PM, revealed she completed sections B, D, E,E (these sections focus on the residents' functional abilities) and Q (this section is designed to explore the residents' interest in returning to community) on the MDS form and the MDS nurse would take that data and create a care plan. She said she recalled the care plan meeting on 10/9/25 with Resident #1 and his family. She said in attendance were the MDS nurse, the DOR (who was currently on leave), and herself. She said in the care plan meeting they talked about goals for discharge, colitis, needing PRN Imodium, open area on his bottom and diet changes due to digestive issues. She said care planning meetings were important to establish care needs for the residents. She said failure to implement a care plan would result in residents not getting their needs met. In a phone interview with the MDS nurse on 11/12/25 at 3:24 PM, revealed she was driving and did not have access to her records. She said she was responsible for initiating care plans and she did not know how Resident #1's comprehensive care plan got missed. She stated she did not complete skin and pressure ulcers on the care plan because she was currently working remotely and did not see the residents herself. She said it was DON's responsibility to complete the skin care plan. She said the Residents care plan should have been developed within 7 days of admission to the facility. She said care plans were important to formulate the concerns and risks, and for staff to be able to look and see what the issues were, areas of concern and interventions in place. She said, I don't know how we dropped the ball. She said moving forward they would work as a team and collaborate and not just depend on one person to complete the care plan. In an interview with the ADON on 11/12/25 at 4:03 PM, revealed she did not attend the care plan meeting. She said she did wound rounds with the wound doctor, but she did not recall seeing Resident #1. She said she did not order an air mattress because his wounds did not meet the requirements. She said if his wound met the requirement, she would have ordered the mattress. She said the order of air mattress took 24 hours to deliver. She said the care plan was completed by the DON, therapy team and MDS nurse. She said she was not told that care plan was part of her scope. She said it was important to have a care plan because you get a holistic picture of the resident's care. She said the failure was that not having a care plan makes it hard to determine what we were treating. She said not having a care plan is like not having a road map/plan for direction of care. In an interview with the admissions nurse on 11/12/25 at 4:47 PM, revealed she had nothing to do with care plans. She said she collaborated with clinical staff and SW to get rooms ready for admission, making sure they had items in room and name on the door. She said the care plans was not part of her scope of practice. In an interview with the DON on 11/12/25 at 5:01 PM, revealed he was on vacation during the period when Resident #1 was in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 3 of 6 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 11/12/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete facility. He said normally the expectation was he was present during the care plan meetings. He said the MDS nurse should have completed the comprehensive care plan. He said the care plan was in place so treatments were done. He said the expectation was the baseline care plans were completed first and then comprehensively thereafter. He said the ADON should have completed the pressure ulcer section because she did the skin assessments, or she should have given the information to the MDS nurse to complete the care plan for skin integrity. He said it was everyone's [DON, ADON, and MDS nurse's] responsibility to make sure care plans were made. He said this information was not communicated with him and he was not aware of missing care plans. He said the risk was not having direction of care. Attempted interview with the DOR by phone on 11/12/25 at 3:32 PM, was unsuccessful. The DOR did not answer or call back. In an interview with the ADM on 11/12/25 at 5:50 PM, he stated the expectation was each resident had both baseline and comprehensive care completed in a timely manner. He said he was not sure how this care plan got missed. He said the expectation was the MDS nurse initiated the care plans and the DON supervised it was done. He said moving forward he would have checks in place and have the DON complete care plan audits. He said care plans are important to direct care for the residents. Record review of the facility's policy titled Care Plan-Resident, dated 12/2016, reflected staff must develop a comprehensive care plan to meet the needs of the residents with measurable and time limited goals. Event ID: Facility ID: 676351 If continuation sheet Page 4 of 6 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 11/12/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure accurately documented skilled nurse notes for Resident #1 on 10/16/25 when RN A documented Resident #1 was a female, he had a left hip fracture, was forgetful, had poor motor coordination, and had balance problems when standing. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the residents' care and place residents at risk for harm due to inaccurate records. Findings include: Record review of Resident #1's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included high cholesterol, essential (primary) hypertension (high blood pressure), enlarged prostate with lower urinary tract symptoms (urinary difficulty due to enlarged prostate), unspecified diarrhea, ileus (this is temporary slowing or cessation of intestinal movement), colitis (this is inflammation of the colon which may cause abdominal pain, diarrhea and sometimes blood in stool), orthopedic after care, and abnormalities of gait and mobility, atherosclerotic heart disease of native coronary artery without angina pectoris (this is a disease that causes hardening and narrowing of arteries). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. Resident #1 required a walker and a manual wheelchair. Resident #1 required partial/moderate assistance for toileting and lower body dressing and supervision for upper body dressing, personal care and rolling left to right in the bed. Record review of Resident #1's care plan, initiated 10/20/25, was incomplete. Record review of skilled progress note, dated 10/16/25 at 5:44 PM, by RN A, reflected, The patient is in bed, alert and oriented. No s/s of discomfort noted. She was diagnosed with left hipfracture, s/p Left hemiarthroplasty. The incision is dry and well-approximated. No s/s of infection. She exhibitsgeneralized weakness related to her diagnosis. She needs max assistance with ADLs. She is participating inskilled nursing services for rehabilitation. She is making good progress. During an interview with Resident #1's family on 11/12/25 at 9:47 AM, revealed on departure from the facility they requested Resident #1's records. She said the facility documented a different resident in the skilled notes, dated 10/16/25. She stated Resident #1 did not have a left hip fracture. In an interview with RN A on 11/12/25 at 1:30 PM, revealed he took care of Resident #1 while in the facility. He said he did not know why he documented the wrong information in Resident #1 chart. He said the facility had a high turnover of residents, and he may have mistakenly entered the notes while thinking of a different resident. He said it was an honest mistake. He said record accuracy was important for treatment decisions. In an interview with the DON on 11/12/25 at 5:01 PM, revealed he was not aware of the inaccurate record sent at discharge. He said the expectation was when documenting to have the right patient in front of you while documenting. He said it was important to keep an accurate record, so the correct treatments were given. He said the risk was record discrepancy. He said he would complete a one-on-one in-service. In an interview with the ADM on 11/12/25 at 5:50 PM, he said he expected the nurses to correctly input residents' records. He said he was not aware of an inaccurate record sent at discharge. He said he expected all staff to follow the facility policies and in-services would be completed. Record review of the facility's Charting and Documentation policy and procedure, revised July 2017, reflected: Service Standard: All services provided to the resident, progress toward care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 5 of 6 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 11/12/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm goals, or changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the intradisciplinary team regarding the resident's condition and response to care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 6 of 6