Health inspection·September 9, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the state Agency) and the administrator of the facility for 1 of 1 resident reviewed for reporting abuse. CNA A failed to notify the ADM and DON about an accident/hazard regarding Resident #1 that happened on 08/27/25. This failure could place residents at risk for abuse and neglect. Findings included:Record Review of Resident #1's face sheet, dated 09/09/25, reflected a [AGE] year-old female with an initial admission date of 03/24/25 and a re-admission date of 09/03/25. Resident #1 had diagnoses of Paraplegia (loss of voluntary movement and sensation in the lower half of the body), Personality Disorder (mental health conditions characterized by long-term patterns of thinking, feeling, and behaving that deviate significantly from societal expectations and cause distress or impairment in various aspects of life), Anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease), Post-Traumatic Stress Disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as a natural disaster, violent crime, or serious accident), Paralytic Syndrome (a medical condition characterized by muscle weakness or paralysis), Tobacco Use, Neuromuscular Dysfunction of Bladder (a condition where the nerves and muscles that control bladder function are impaired)Lack of Coordination (the inability to perform smooth, precise, and controlled movements).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], reflected: Section B Hearing, Speech, and Vision reflected that Resident #1 had clear speech and Vision, had the ability to make herself understood and had the ability to understand others. Section C Brief Interview for Mental Status score reflected a score of 15, which indicated the resident's cognition was normal. Record review of Resident #1's Care Plan, dated 09/09/25, reflected the following:‘Focus'Resident #1 utilizes a motorized wheelchair to move around in the room/facility. Resident #1 has been evaluated by Therapy in the usage of a power wheelchair.‘Goal'Safe use daily of the electric wheelchair by Resident #1.‘Interventions/Tasks'Transfer: The resident is able to transfer self but should use x1 staff for participation in safety.Resident#1 educated on safe use of electric wheelchair, not to allow other residents to hold on to the back on her wheelchair while in operation. In an interview on 09/09/25 at 9:54 AM, Resident #1 stated on 08/27/25 CNA A came in her room pissed off that she had work the 300 hall. Resident #1 stated she was soaked in urine and CNA A changed her diaper, but her bed was soaked in urine. Resident #1 stated she had asked CNA A if she was going to change the bed sheets, and CNA A responded she would change the sheets when Resident #1 got out of bed. Resident #1 stated she told CNA A that she was ready to get out of bed and that's when CNA A started transferring her to the motorized wheelchair. Resident #1 stated CNA A then pushed a Page 1 of 5 455494 455494 09/09/2025 Glenview Wellness & Rehabilitation 7625 Glenview Dr North Richland Hills, TX 76180

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few button on the motorized wheelchair and the wheelchair ran into the wall and hit Resident #1's foot when the wheelchair hit the wall. Resident #1 stated that her foot was in pain at the time of the incident, but it was no longer in pain at the time of the interview. In an interview on 09/09/25 at 10:44 AM, CNA A stated she was getting Resident #1 ready to go outside for her smoke break. CNA A said she had gotten the motorized wheelchair next to the bed so Resident #1 could transfer from the bed to the wheelchair. CNA A stated that she pressed the joystick on the motorized wheelchair and the wheelchair zoomed off fast and hit the wall and Resident #1's right foot. CNA A told Resident #1 that she was going to get the nurse and Resident #1 stopped CNA A and stated she was fine and not in any pain and that it was not a big deal. CNA A stated that she was unsure why she did not report the incident immediately to a nurse. She stated that she meant to report it to a nurse when the incident happened, but she had forgot to report it because she was doing multiple things at once. She stated the risk of not reporting incident/accidents in a timely manner can prolong care and it is bad to not report. CNA A stated she was inserviced on how to properly use the motorized wheelchair by unlocking the wheelchair from the bottom and pushing it manually next time. In an interview on 09/09/25 at 2:03 PM, the DON stated that the incident happened on 08/27/25. The DON stated she did not find out about the incident until the next day on 08/28/25 when Resident #1 went to the DON and voiced that she was going to make a complaint to the state and that's when Resident #1 told her that her foot was hurting because of the motorized wheelchair hitting her foot and she requested some pain medicine. The DON stated that she immediately assessed Resident #1's foot, and orders were submitted for x-rays on 08/29/25. The DON stated x-ray results returned on 08/30 were negative, which indicated no injuries. The DON stated she expects staff to report all incidents to a nurse. The DON stated if a nurse was not available then she expects staff to report all incidents to her immediately. She stated the risk of staff not reporting incidents in a timely manner can cause care to be delayed. The DON stated if they would have known about the incident when it first occurred staff could have implemented the next steps right away. In an interview on 09/09/25 at 3:06 PM, the ADM stated that she had found out about the wheelchair hitting Resident #1's foot when the DON came to her on 08/28/2025. ADM stated that she immediately made an incident report to the state. She stated that Resident #1 knows how to adjust the speed on the motorized wheelchair, and she increases the speed on the wheelchair all the time. The ADM stated that when she was made aware of the incident she immediately went and had the wheelchair assessed by therapy to be sure the wheelchair was set to a safe speed. ADM stated the CNA has been in service on how to properly use the motorized wheelchair. ADM stated the risk of a CNA not knowing how to properly operate a motorized wheelchair can cause residents to get hurt. ADM stated her expectations of the CNA are to get assistance from therapy before operating the motorized wheelchair. Review of the facility policy, Abuse & Neglect, date revised 08/20 reflected: I. The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. The administrator is responsible for coordinating and implementing the Facility' abuse prevention policies, ii. Facility Staff will report known or suspected instances of abuse to the administrator, and his/her designee. A. Reporting Requirements i. If the reportable event does not result in serious bodily injury, the administrator, and his/her designee, will make a telephone report to the local law enforcement agency within 24 hours of the observation, knowledge, or suspicion of physical/sexual 455494 Page 2 of 5 455494 09/09/2025 Glenview Wellness & Rehabilitation 7625 Glenview Dr North Richland Hills, TX 76180

F 0609 abuse. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455494 Page 3 of 5 455494 09/09/2025 Glenview Wellness & Rehabilitation 7625 Glenview Dr North Richland Hills, TX 76180

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that each resident received adequate supervision for one (Resident #1) of three residents reviewed for supervision and ensured the environment remained free of accidents hazards. The facility failed to ensure CNA A appropriately transferred Resident #1 from the bed to the motorized wheelchair to ensure accidents did not occur. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and injury. Findings included: Record Review of Resident #1's face sheet, dated 09/09/25, reflected a [AGE] year-old female with an initial admission date of 03/24/25 and a re-admission date of 09/03/2025. Resident #1 had diagnoses of Paraplegia (loss of voluntary movement and sensation in the lower half of the body), Personality Disorder (mental health conditions characterized by long-term patterns of thinking, feeling, and behaving that deviate significantly from societal expectations and cause distress or impairment in various aspects of life), Anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease), Post-Traumatic Stress Disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as a natural disaster, violent crime, or serious accident), Paralytic Syndrome (a medical condition characterized by muscle weakness or paralysis), Tobacco Use, Neuromuscular Dysfunction of Bladder (a condition where the nerves and muscles that control bladder function are impaired), Lack of Coordination (the inability to perform smooth, precise, and controlled movements).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], reflected: Section B Hearing, Speech, and Vision reflected that Resident #1 had clear speech and Vision, had the ability to make herself understood and had the ability to understand others. Section C Brief Interview for Mental Status score reflected a score of 15, which indicated the resident's cognition was normal. Record review of Resident #1's Care Plan, dated 09/09/25, reflected the following:‘Focus'Resident #1 utilizes a motorized wheelchair to move around in the room/facility. Resident #1 has been evaluated by Therapy in the usage of a power wheelchair.‘Goal'Safe use daily of the electric wheelchair by Resident #1.‘Interventions/Tasks'Transfer: The resident is able to transfer self but should use x1 staff for participation in safety.Resident#1 educated on safe use of electric wheelchair, not to allow other residents to hold on to the back on her wheelchair while in operation. In an interview on 09/09/25 at 9:54 AM, Resident #1 stated on 08/27/25 CNA A came in her room pissed off that she had work the 300 hall. Resident #1 stated she was soaked in urine and CNA A changed her diaper, but her bed was soaked in urine. Resident #1 stated she had asked CNA A if she was going to change the bed sheets, and CNA A responded she would change the sheets when Resident #1 got out of bed. Resident #1 stated she told CNA A that she was ready to get out of bed and that's when CNA A started transferring her to the motorized wheelchair. Resident #1 stated CNA A then pushed a button on the motorized wheelchair and the wheelchair ran into the wall and hit Resident #1's foot when the wheelchair hit the wall. Resident #1 stated that her foot was in pain at the time of the incident, but it was no longer in pain at the time of the interview. In an interview on 09/09/25 at 10:44 AM, CNA A stated she was getting Resident #1 ready to go outside for her smoke break. CNA A said she had gotten the motorized wheelchair next to the bed so Resident #1 could transfer from the bed to the wheelchair. CNA A stated that she pressed the joystick on the motorized wheelchair and the wheelchair zoomed off fast and hit the wall and Resident #1's right foot. CNA A told Resident #1 that she was going to get the nurse and Resident #1 stopped CNA A and stated she was fine and not in any pain and that it was not a big deal. CNA A stated that she was unsure why she did not report the incident immediately to a nurse. She stated that she meant to report it 455494 Page 4 of 5 455494 09/09/2025 Glenview Wellness & Rehabilitation 7625 Glenview Dr North Richland Hills, TX 76180

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to a nurse when the incident happened, but she had forgotten to report it because she was doing multiple things at once. She stated the risk of not reporting incidents in a timely manner can prolong care and it is bad to not report. CNA A stated she was inserviced on how to properly use the motorized wheelchair by unlocking the wheelchair from the bottom and pushing it manually next time. In an interview on 09/09/25 at 2:03 PM, the DON stated that the incident happened on 08/27/25. The DON stated she did not find out about the incident until the next day on 08/28/25 when Resident #1 went to the DON and voiced that she was going to make a complaint to the state and that's when Resident #1 told her that her foot was hurting because of the motorized wheelchair hitting her foot and she requested some pain medicine. The DON stated that she immediately assessed Resident #1's foot, and orders were submitted for x-rays on 08/29/25. The DON stated x-ray results returned on 08/30 were negative, which indicated no injuries. The DON stated she expects staff to report all incidents to a nurse. The DON stated if a nurse was not available then she expects staff to report all incidents to her immediately. She stated the risk of staff not reporting incidents in a timely manner can cause care to be delayed. The DON stated if they would have known about the incident when it first occurred staff could have implemented the next steps right away. In an interview on 09/09/25 at 3:06 PM, the ADM stated that she had found out about the wheelchair hitting Resident #1's foot when the DON came to her on 08/28/2025. ADM stated that she immediately made an incident report to the state. She stated that Resident #1 knows how to adjust the speed on the motorized wheelchair, and she increases the speed on the wheelchair all the time. The ADM stated that when she was made aware of the incident she immediately went and had the wheelchair assessed by therapy to be sure the wheelchair was set to a safe speed. ADM stated the CNA has been in service on how to properly use the motorized wheelchair. ADM stated the risk of a CNA not knowing how to properly operate a motorized wheelchair can cause residents to get hurt. The ADM stated her expectations of the CNA are to get assistance from therapy before operating the motorized wheelchair. On 09/09/25 at 4:04 PM, surveyor requested a policy for accidents/hazards, but the ADM stated that they did not have a policy on accidents/hazards. 455494 Page 5 of 5