Park Village Healthcare And Rehabilitation

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the designated representative. She stated that the residents were at risk of ongoing abuse when the designated representative was not notified.In a telephone interview on 11/21/25 at 10:35 AM with the NP,

he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents' rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. Record review of the facility Change of Condition policy revised 07/2015, reflected change in condition reporting 3. Licensed nurse will inform family/responsible party of change of condition and document notification. 4. All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Village Healthcare and Rehabilitation

207 E Parkerville Rd Desoto, TX 75115

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

addressed including reeducation and/or counseling. 11/15/2025 at 12:32pm Resident #1 observation-He was in his room laying in his bed watching a women's soccer game on TV. He spoke to the surveyor and smiled. He stated that he was doing fine. Surveyor spoke to CNA-D who stated this hall is for men only. She stated that Resident #1 had been out of his room to smoke a cigarette, watch TV and had spoken to some of the men. She stated that Resident #1 had been in a good mood and there had not been any incidents since he had been on one-to-one supervision.11/15/2025 at 12:39pm Resident #2 observation she was sitting in the dining room at a table. She did not respond to surveyor when surveyor spoke to her. Resident #2 was dressed appropriately and did not make any eye contact with surveyor. Surveyor spoke to CNA-E, and she stated Resident #2 had been doing well. CNA-E stated Resident #2 does not appear to be sad.

CNA-E stated Resident #2 had been eating. CNA-E stated Resident #2 normally did not talk. Interviews with CNA-A, LVN-B, LVN-C, CNA-D, CNA-E, CNA-F, LVN-G, CNA-H, CNA-I, CNA-J, LVN-K, LVN-L, CNA-M, LVN-N, CNA-O, CNA-P, Staffing Coordinator, and ADON on 11/15/25 from 12:48 PM - 2:55 PM and interviews with LVN-Q, LVN-R, CNA-S, and LVN-T on 11/15/25 from 5:30 PM - 6:25 PM revealed, they had been in-serviced/educated on who the abuse coordinator was at the facility, how and who to report abuse to if they witnessed or suspected abuse. All staff stated they received re-education of inappropriate touching between residents and who it should be reported to and the time frame should be immediate.

They stated residents who exhibit aggressive or inappropriate behaviors should be placed on 1:1 supervision immediately, notify the nurse management and administrator immediately. Interviews with LVN's revealed they knew they should call the police, send the resident to the ER for examination for inappropriate touching and abuse. LVN's interviewed also stated they had been re-educated on how to determine a change in condition and that the medical provider and family should be notified. They stated a change in condition would be weight, cognition, infection or new medications and that abuse/neglect would be considered a change in condition. The Administrator was informed that the Immediate Jeopardy was removed on 11/15/2025 at 3:35 PM. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Village Healthcare and Rehabilitation

207 E Parkerville Rd Desoto, TX 75115

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

care. The Administrator was asked, If nothing happed between Resident #1 and Resident #2, how did Resident #2 end up without a brief, Resident #1 with a dirty brief to put in the trash, and they were the only two people in the room? He stated he could not assume that anything had happened between the residents because there were no witnesses. The Administrator stated the residents were at risk of the facility not creating an environment for resident safety. Record review of facility Abuse and Neglect Policy revised 10.2022 reflected, Facility staff with knowledge of an actual or potential violation of this policy must report

the violation to his or her supervisor or the Facility administrator immediately. The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident,

the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.Record review of Long-Term Care Regulation Provider Letter dated 08/29/24 reflected, 2.1 Incidents that a NF Must Report to HHSC A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse1

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Village Healthcare and Rehabilitation

207 E Parkerville Rd Desoto, TX 75115

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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Administrator continued to meet with surveyor, record review of in-service training and education dated 11/14/25 and 11/15/25 completed by the Cluster nurses (nurses from sister facilities and regional staff.

Record review of LVN, RN, ADON change in condition in-service dated 11/14/25 and 11/15/25 for all three shifts. Record review of ad hoc meeting notes dated 11/14/25 Attendees included the Medical Director by phone, Clinical Resource, DON, ADON, Administrator. Record revied of undated knowledge checks used to assess the knowledge of nursing staff. Record review of in-service dated 11/14/25 for Administrator and DON to investigate and report any allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11/15/2025 at 12:32pm Resident #1 observation-He was in his room laying

in his bed watching a women's soccer game on TV. He spoke to the surveyor and smiled. He stated that he was doing fine. Surveyor spoke to CNA-D who stated this hall is for men only. She stated that Resident #1 had been out of his room to smoke a cigarette, watch TV and had spoken to some of the men. She stated that Resident #1 had been in a good mood and there had not been any incidents since he had been on one-to-one supervision.Interviews with CNA-A, LVN-B, LVN-C, CNA-D, CNA-E, CNA-F, LVN-G, CNA-H, CNA-I, CNA-J, LVN-K, LVN-L, CNA-M, LVN-N, CNA-O, CNA-P, Staffing Coordinator, and ADON on 11/15/25 from 12:48 PM - 2:55 PM and interviews with LVN-Q, LVN-R, CNA-S, and LVN-T on 11/15/25 from 5:30 PM - 6:25 PM revealed, they had been in-serviced/educated on who the abuse coordinator was at the facility, how and who to report abuse to if they witnessed or suspected abuse. All staff stated they received re-education of inappropriate touching between residents and who it should be reported to and

the time frame should be immediate. They stated residents who exhibit aggressive or inappropriate behaviors should be placed on 1:1 supervision immediately, notify the nurse management and administrator immediately. Interviews with LVN's revealed they knew they should call the police, send the resident to the ER for examination for inappropriate touching and abuse. LVN's interviewed also stated they had been re-educated on how to determine a change in condition and that the medical provider and family should be notified. They stated a change in condition would be weight, cognition, infection or new medications and that abuse/neglect would be considered a change in condition. The Administrator was informed that the Immediate Jeopardy was removed on 11/15/2025 at 3:35 PM. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Event ID:

Facility ID:

If continuation sheet