Health inspection·April 27, 2023

F 0642 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #109's EMR on 04/27/23 reflected a 5-day MDS assessment, marked accepted on 12/19/22, but no discharge MDS listed. An interview on 04/27/23 at 2:23 PM with the MDS Coordinator revealed she checked in the EMR for the discharge MDS submissions and did not see them. She said they would show up there if they were done, and they were not done. She said the discharge MDS was to let CMS know someone had been discharged , but she did not know what would happen if they did not know. She would have been the person to submit them, because she did the Medicare MDS submissions, but she did not know why they were not done. She agreed she would get back to the surveyor after she had a chance to investigate. An interview on 04/27/23 at 3:44 PM with the MDS Coordinator revealed she confirmed the discharge MDS were not done for Resident #24 and Resident #109, but she did not know why. Review of the Resident Assessment policy, dated 01/12/20, reflected it did not address discharge MDS specifically. Review of the Chapter 2: The Assessment Schedule for the RAI, Revised 12/02, and accessed on 04/28/23 at 3:32 PM, at https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MinimumDataSets20/Download reflected A Discharge-return not anticipated ( .) is completed when it is determined that the resident is being discharged with no expectation of return after a comprehensive admission assessment has been completed. A discharge with return not anticipated can be a formal discharge to home, to another facility ( .) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676358 If continuation sheet Page 2 of 8 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 676358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, record review, and interview, the facility failed ensure all drugs and biologicals were stored securely, provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one (Hall 500 Medication Cart) of four medication carts reviewed for pharmacy services and one (300 hall) of two refrigerators reviewed for labeling and storage for compliance. The facility failed to ensure expired medications in nurse medication carts for Hall 500 and refrigerator for 300 halls were removed and destroyed. The failure placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart and in the refrigerator . Findings included: Observation on 04/26/23 at 02:51 PM of the nurse's medication cart used for the 500 Hall with LVN A revealed, one insulin vial of gargaline 100 unit/ml with an opening date of 3/26/23 with instruction to discard after 28 days and 2 bottles of debrox ear wax with an expiry date of 02/15/23. Interview on 04/26/23 at 03:00 PM with LVN A revealed it is all nurse's responsibility to check the carts for expired medications every shift and put them in the destruction boxes. She stated she did not check the cart after being handed over she forgot. She stated the side effects of giving expired medication was they will not work and will not be effective. She stated she had not been trained on labeling and storage. Observation on 04/26/23 at 03:37 PM of the 300 Hall refrigerator revealed one packet of Bisacodyl suppository, with an expiry date of 03/23. Interview on 04/26/23 at 03:40 PM with RN C revealed it was all nurses and mangers responsibility to check and ensure medications are labeled and not expired .She stated they are supposed to check each shift and she did not check when she came to work, she forgot . She stated the side effects of giving expired medication was they will not work and will not be effective. She stated all expired medications are supposed to be removed from the refrigerator and carts and put on destruction boxes for pharmacist to destroy .She stated she had done training on storage and labelling . Interview on 04/27/23 at 08:46 AM with the DON revealed his expectation was that all nurses check their carts for expired medications every shift. He stated he was made aware there were expired medications in the refrigerator and on the cart . He stated the ADON was supposed to check the carts and the refrigerator once a week for expired medications and checking on dates and labeling .He stated he had done in services on all staff on 04/22/23 on removal of expired medications from the carts and refrigerators and putting them on the destruction boxes. He stated the risk of having expired medications on carts and in refrigerators they will not be effective . He stated short acting insulin are good for 28 days after opening date and if administered to residents it will not be effective as it is expected. Interview on 04/27/23 at 09:15 AM with ADON D, who was responsible for monitoring the refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676358 If continuation sheet Page 3 of 8 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 676358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 300 Hall, revealed it was her responsibility to go behind the nurses to check whether they are removing the expired medications on carts and refrigerators. She stated she was supposed to have caught the mistakes. ADON D stated she could not remember the last time she checked the 300 Hall refrigerator. She stated the night shift nurses are assigned to check the refrigerator and she audit .ADON Stated failure to check for the expired medication and document the right temperature was that the staff would not know whether the medications were still potent for resident use. ADON D stated she had done training with staff on refrigerator logs and on checking of expired medications on carts and refrigerator. Interview on 04/27/23 at 09:43 AM with ADON E, who was responsible for monitoring the medication carts and refrigerator on 500 Hall revealed it was her responsibility to go behind the nurses and check whether the temperatures were within normal ranges and were being documented correctly on the temperature log. She stated she was also responsible to check the carts after nurses for expired medications. ADON E stated the normal temperatures should be between 36 degrees and 40 degrees Fahrenheit. ADON E stated the last time she checked on temperatures and documentation on 500 Hall medication carts and refrigerators had been 2 weeks ago. She stated failure to check the carts and refrigerator for expired medications and temperature logs could result in the medications being ineffective. ADON E stated she had done training with staff on refrigerator logs and on expired medications. Review of the facility's policy Storage of Medications, revised April 2007, reflected: 2. In order to limit access to prescription medications, medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 11. Medication requiring refrigeration or temperatures 2 degrees centigrade (36 degrees Fahrenheit) and 8 degrees centigrade(46degrees Fahrenheit) are kept in a refrigerator with temperature to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits . 12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. 14. Outdated, contaminated ,discontinued or deteriorated medications and those in containers that are cracked ,soiled ,or without secure closures are immediately removed from the stock, disposed of according to procedures for medication disposal and reordered from pharmacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676358 If continuation sheet Page 4 of 8 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 676358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for one (500 Hall refrigerator) of two medications storage refrigerators, led to ensure all drugs and biologicals were stored securely, provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for two (Hall 500 and 700 Medication Cart) of four medication carts reviewed for pharmacy services and one (300 hall) two refrigerators reviewed for labeling and storage for compliance. 1.The facility failed to ensure the temperatures for the medication refrigerators for the 500 hall was being checked and documented. 2. Facility failed to ensure the cart for 700 hall remained locked when not in use or attended by persons with authorized access. The failure placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart, in the refrigerator and due to improper temperature control monitoring and documenting. Findings included: Observation on 04/26/23 at 02:51 PM of the nurse's medication cart used for the 500 Hall with LVN A revealed, one insulin vial of gargaline 100 unit/ml with an opening date of 3/26/23 with instruction to discard after 28 days and 2 bottles of debrox ear wax with an expiry date of 02/15/23. Observation on 04/26/23 at 2:55 PM of the 500 Hall refrigerator revealed Lantus, NovoLog, Levemir insulin pens , Phenergan suppository, were labeled and dated, and the refrigerator thermometer reading was 40 degrees Fahrenheit. The refrigerator temperature log sheet revealed the temperatures for April 2023 were documented as follows: 04/1/23 - 36 degrees Fahrenheit - 7:00 AM 04/2/23 - 22 degrees Fahrenheit - 8:00 AM 04/3/23 - 39 degrees Fahrenheit - 8:00 AM 04/4/23 - 28 degrees Fahrenheit - 8:00 AM 04/5/23 - 26 degrees Fahrenheit - 8:00 AM 04/6/23 - 26 degrees Fahrenheit - 7:00 AM 04/7/23 - 26 degrees Fahrenheit - 8:00 AM 04/8/23 - 26 degrees Fahrenheit - 8:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676358 If continuation sheet Page 5 of 8 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 676358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062 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 0761 04/9/23 - 26 degrees Fahrenheit - 8:00 AM Level of Harm - Minimal harm or potential for actual harm 04/10/23 - 26 degrees Fahrenheit - 8:00 AM 04/11/23 - 28 degrees Fahrenheit - 7:00 AM Residents Affected - Some 04/12/23 - 28 degrees Fahrenheit - 8:00 AM 04/13/23 -28 degrees Fahrenheit - 8:00 AM 04/14/23 - 28 degrees Fahrenheit - 8:00 AM 04/15/23 - 28 degrees Fahrenheit - 8:00 AM 04/16/23 - 28 degrees Fahrenheit - 7:00 AM 04/17/23 - 29 degrees Fahrenheit - 8:00 AM 04/18/23 - 29 degrees Fahrenheit - 8:00 AM 04/19/23 - 29 degrees Fahrenheit - 8:00 AM 04/20/23 - 26 degrees Fahrenheit - 8:00 AM 04/21/23 - 28 degrees Fahrenheit - 7:00 AM 04/22/23 - 26 degrees Fahrenheit - 8:00 AM 04/23/23 - 28 degrees Fahrenheit - 8:00 AM 04/24/23 - 28 degrees Fahrenheit - 8:00 AM 04/25/23 - 28 degrees Fahrenheit - 8:00 AM 04/26/23 - 28 degrees Fahrenheit - 7:00 AM Recommended temperature guides for refrigerated storage were 36-40 degrees Fahrenheit as per the temperature log. Interview on 04/26/23 at 03:00 PM with LVN A revealed the refrigerators and logs were supposed to be checked and documented by the night shift nurses because that was their scheduled task, but it was all nurses' responsibility to check the temperatures. She stated she was aware the right temperatures are 36-46 degrees Fahrenheit . She also stated it is all nurse's responsibility to check the carts for expired medications every shift and put them in the destruction boxes. She stated she did not check the cart after being handed over she forgot. She stated the side effects of giving expired medication was they will not work and will not be effective. She stated she had not been trained on labeling and storage. She stated if medications are stored in low temperatures, they will lose the potency and they will be ineffective if administered to residents . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676358 If continuation sheet Page 6 of 8 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 676358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 04/26/23 at 03:03 PM revealed, there was a cart left open for 6 minutes on the 700 hall that remained un- locked when not in use or attended by persons with authorized access and residents were observed up and down the hall. Interview on 04/26/23 at 03:00 PM with LVN B revealed she was the one that left the cart open. She stated she forgot to lock when she went to a resident's room. She stated the benefit of locking the cart was safety . She stated the risk of leaving the cart open ,the resident would get to the cart and take medications that might harm them. She also stated it may contribute to medication diversion. She stated she had training on safety and locking of the cart while not in use . Interview on 04/27/23 at 08:46 AM with the DON revealed his expectation was that nurses would check the refrigerator temperatures and document them on the log. He stated it is also his responsibility to monitor but he had not done so he was relying on his ADON's. He stated he does not think his staffs were reading the instructions on the temperature log that guides them on the correct temperature's ranges of 36-46 degrees Fahrenheit . If the temperatures were not accurate, they would notify him, the ADON, and Maintenance for thermometer replacement. The DON stated the ADON's were assigned to monitor the refrigerators in the medication rooms. The DON stated the staff , who had been checking and documenting, were trained and he has been reminding them on correct reading and documenting temperatures during their staffs monthly meeting. The DON stated the effects of the temperatures being all medications stored in the refrigerators will not be effective and would not be potent. He also stated his expectation is that staff should lock their carts at all times, because they have residents that can get into the cart. He stated the risk the resident can take medications that can harm them. He stated He does not think he has done training on cart locking but he has been addressing the safety of carts during his monthly meeting. Interview on 04/27/23 at 09:43 AM with ADON E, who was responsible for monitoring the medication carts and refrigerator on 500 Hall revealed it was her responsibility to go behind the nurses and check whether the temperatures were within normal ranges and were being documented correctly on the temperature log. She stated she was also responsible to check the carts after nurses for expired medications. ADON E stated the normal temperatures should be between 36 degrees and 40 degrees Fahrenheit. ADON E stated the last time she checked on temperatures and documentation on 500 Hall medication carts and refrigerators had been 2 weeks ago. She stated failure to check the carts and refrigerator for expired medications and temperature logs could result in the medications being ineffective. ADON E stated she had done training with staff on refrigerator logs and on expired medications. Interview on 04/27/23 at 12:01 PM with LVN F, who worked night shift. He stated he had been getting the readings from the thermometer inside the fridge. He stated he was not sure of the right temperatures, and he did not read the instruction on the temperature log and if he did, he did not understand . LVN F stated he did not see the need of notifying the management since he did not know whether the temperatures were incorrect .He stated he has not done training on reading and documenting refrigerator readings. LVN F stated he does not know what will happen if the medication were stored in low temperatures because he is not a pharmacist. He stated after he was trained, he now knows the correct temperatures are 36-46 degrees Fahrenheit. Review of the facility's policy Storage of Medications, revised April 2007, reflected: 2. In order to limit access to prescription medications, medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676358 If continuation sheet Page 7 of 8 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 676358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 11. Medication requiring refrigeration or temperatures 2 degrees centigrade (36 degrees Fahrenheit) and 8 degrees centigrade(46degrees Fahrenheit) are kept in a refrigerator with temperature to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits . 12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. 14. Outdated, contaminated ,discontinued or deteriorated medications and those in containers that are cracked ,soiled ,or without secure closures are immediately removed from the stock, disposed of according to procedures for medication disposal and reordered from pharmacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676358 If continuation sheet Page 8 of 8