Health inspection·November 19, 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 interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 2 residents (Residents #1 and #2), reviewed for abuse, neglect, and exploitation.The facility failed to report an incident of resident to resident abuse between Resident #1 and Resident #2 that occurred on 10/10/2025.This failure could place residents at risk of abuse, neglect and exploitation.Findings included:Resident #1Record review of Resident #1's admission record, dated 10/21/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of vascular dementia (a type of dementia caused by reduced blood flow to the brain). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Record review of Resident #1's care plan initiated 10/10/25, revealed Resident #1 was the receiver of aggression from another resident and sustained injury to the skin as noted in skin injury care plan. Interventions included the following: - Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document.- Assess and address for contributing sensory deficits- Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.Monitor resident frequently. Document observed behavior and attempted interventions in behavior log.Separate from potential resident to resident incidents. Take to another area away from resident or residents to calm down and keep safe. If needed, [Health Company Name] eval/treat.Record review of Resident #1's nursing notes, dated 10/10/2025 at 6:57 pm, revealed ADON was notified by attending nurse that [Resident #1] was bleeding. She would not tell him how it happened. This nurse went to the unit with nurse to see if she would tell me and she did. She stated that her roommate [Resident #2] hit her with a hairbrush. She held out her left arm, and you can see the marks made up and down her arm from the bristles of the brush. ADON advised to do incident reports and contact RP for both residents. Residents were separated to avoid further conflict.Record review of Resident #1's nursing notes, dated 7:34 pm, revealed ADON called [RP name] to advise of small marks and [family member] was ok with. She states that she knows her [family member's] skin is fragile. Thanked for calling, no other questions or concerns.Record review of Resident #1's nursing notes, dated 10/10/2025 at 11:13 pm, revealed Pt walking down the hallway from her room holding her left forearm. Nurse noticed skin tear to back of right hand and bruise to left forearm. Pt denies pain or discomfort.Record review of Resident #1's nursing notes, dated 10/11/2025 at 6:55 am, revealed bruise remains to left forearm, denied pain.Record review of Resident #1's nursing notes, dated 10/12/2025 at 10:00 pm, revealed Resident continues with fading bruise to left forearm. Refuses to take wrap off. No concerns voiced all Page 1 of 6 455494 455494 11/19/2025 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 day. Will continue with plan of care in place.Record review of Resident #1's nursing notes, dated 10/13/2025 at 9:20 pm, revealed Resident assisted to another room temporary for tonight due to previous roommate separation and room mate noted to attempt to wander into previous room, notified RP of resident having room change for tonight to ensure separation .Record review of Resident #1's nursing notes, dated 10/13/2025 at 11:28 pm, revealed No behaviors noted on shift.Record review of Resident #1's nursing notes, dated 10/13/2025 at 11:33 pm, revealed skin noted injured with bleeding, non-intact. When asked what happened pt states; ‘She did it point at the other pt.Record review of Resident #1's nursing notes, dated 10/14/2025 at 7:41 am, revealed bruise on the left forearm is fading, no behavior observed last night.Record review of Resident #1's nursing notes, dated 10/14/2025 at 3:03 pm, revealed, Resident alert/verbal, no s/sx pain or discomfort, area to right forearm appears dry, no discomfort per resident.Record review of Resident #1's nursing notes, dated 10/14/25 at 4:35 pm, revealed, Spoke to [RP name] regarding resident room change to [room number].Record review of Resident #1's nursing notes, dated 10/14/2025 at 4:35 pm, revealed Verbalized understanding also discussed wound care to left forearm. Discussed about the healing and improvement of area and area is has scabbed over no sign or symptoms of infection.Record review of Resident #1's nursing notes, dated 10/15/2025 at 6:08 am, revealed Resident slept in the new room [number] with no behavior noted.Resident #2Record review of Resident #2's admission record, dated 10/22/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia (dementia without a specified type or cause).Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment. Further review of the MDS revealed no physical, verbal or behavioral symptoms directed towards others occurred and Resident #2 wandered daily. Record review of Resident #2's care plan, date initiated 10/10/2025 revealed Resident #2 had potential to demonstrate physical behaviors r/t Dementia. Initiated a door slapping on another resident. Resident #2 appears upset walking behind roommate cursing. Unable to communicate why agitated. Initiated Aggression with another resident. Interventions included the following: - Cognitive Assessment- Assess and address for contributing sensory deficits- COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.- Escorted to DR to calm [Resident #2] down. [Health Company Name] referral for medication review. Labs and U/A to be obtained. Separate residents.Give [Resident #2] as many choices as possible about care and activities.- Medication review per [Health Company Name].-Monitor frequently document observed behavior and attempted interventions in behavior log.-Monitor/document/report to MD of danger to self and others.-Psychiatric/Psychogeriatric consult as indicated.-When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.Record review of Resident #2's nursing notes, dated 10/10/2025 at 8:03 PM, revealed. ADON was called to look over another resident that may have had contact with [Resident #2]. [Resident #2] observed walking up and down the hallway with blood stains on the upper sleeves of the t-shirt that she was wearing. Roommate states that they had an incident with a hairbrush and that [Resident #2] struck her with the brush to her left arm. No bruises, cuts lacerations noted on [Resident #2]. Attending nurse to completed an incident report and call RP to advise of situation. Resident were separated to avoid further conflict. [Resident #2] moved to room [number].Record review of Resident #2's nursing notes, dated 10/10/2025 at 8:15 PM, revealed, Pt following behind the other pt cursing out with some blood stains on her t-shirt. Pt appears upset. She was separated from the other pt. Rp's for both parties notified 455494 Page 2 of 6 455494 11/19/2025 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 and advised of the situation. NP notified and no new order was given. This nurse updated behavior monitoring. Put in new order for [Health Care Company Name] to eval and treat for new behaviors, also to do the GDR.Record review of Resident #2's nursing notes, dated 10/10/25 at 9:19 PM revealed, Psych consult as indicated by Dr [Name], pt moved to another room.Record review of Resident #2's nursing notes, dated 10/14/2025 at 7:15 AM, revealed Resident refused to move into the new room and slept in her old room. The original resident also refused to welcome the new resident when approached. The resident originally assigned to the room stated that she did not want anyone else in her room. Situation will be followed up in AM.Record review of Resident #2's nursing notes, dated 10/16/2025, revealed Depakote increased to 250 mg BID x 10 days from Depakote 125 mg BID. Notified spouse [Name].Interview on 10/21/2025 at 9:06 AM, the Administrator stated there was an incident with Resident #1 and Resident #2. She stated Resident #2 was nonverbal but could say cuss words. She said Resident #2 hit Resident #1 on the arm with a hairbrush, but she could not say what happened. The Administrator stated she did not report this incident to the state agency because Resident #2's BIMS was 0 and there was no intent. She stated she reported based on the provider letter. Observation on 10/21/2025 at 10:10 am, revealed Resident #2 in the memory care unit, walking up and down the hall. Resident #2 appeared well groomed and dressed. Resident #2 was not able to answer surveyor questions. Observation and interview on 10/21/2025 at 10:29 am, revealed Resident #1 in her room, lying in bed. Resident #1 appeared well groomed and dressed. A small scab was observed on the Resident's right hand. Resident #1 stated she did not have a roommate anymore. Resident #1 said they got into a fight and her roommate took a brush and hit her on the arm and also this at the same time. Resident #1 then showed surveyor her right upper arm and 2 circular bruises were observed. The bruises measured approximately 3 inches by 3 inches, and had a slight yellow color around the outside and a purple color in the middle. Resident #1 stated it happened in their room when Resident #2 hit her before. Resident #1 stated she did not fall. Resident #1 stated she told staff, but was not able to tell surveyor who the staff was. Interview on 10/21/2025 at 11:16 am, LVN A stated Resident #1 had an altercation with Resident #2 and had some bruising on her right arm. LVN A stated he did not witness the incident and it happened on second shift. He stated they (staff) was currently monitoring the residents, to keep them from crossing paths, and monitoring their behaviors. Interview on 10/21/25 at 2:33 pm, ADON C stated she was here the evening of the altercation between Resident #1 and Resident #2 but did not witness the incident. She said right after the incident, LVN B wanted her to look at Resident #1's arm. ADON C stated Resident #1's arm had what looked like dots from a brush bristle. She said Resident #1 told her My roommate came in a whacked me. ADON C stated she did not do a full skin assessment just at the lower arms and asked the resident if she was hit anywhere else, which Resident #1 denied. ADON C stated Resident #2 did not answer when she asked about the incident. ADON C stated she did a trauma assessment on both residents, ensured both residents were separated and Resident #2 moved rooms immediately.Interview on 10/21/2025 at 3:30 PM, LVN B stated on 10/10/2025 he was by the nurses station when he saw Resident #1 holding her left arm and saw an indentation on the skin. He said Resident #1 did not want him to look at it, so he got ADON C. LVN B stated Resident #1 and Resident #2 were separated, and Resident #2 did not have any injuries. LVN B stated he did a full skin assessment on Resident #1 and an incident report later that night after she had calmed down. He stated he did not see any bruises on the upper right arm when he assessed her. LVN B stated he was not aware of any current bruises on Resident #1's upper right arm. When asked who was supposed to do the next skin assessment LVN B did not know. LVN B stated it just pops up in the system and it will prompt you. LVN B did not give a reason why the weekly skin assessment was not completed. LVN B stated they were 455494 Page 3 of 6 455494 11/19/2025 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 making sure Resident #1 and Resident #2 did not have another altercation by keeping an eye on them and keeping them separated if they were too close. LVN B stated he had been in serviced on Abuse and Neglect. Interview on 10/21/2024 at 4:32 pm, the Administrator stated she did not report based on the provider letter and because Resident #2's BIMS was 0, she had no intent. The Administrator stated there was no risk for not reporting. When asked why abuse was reported the Administrator stated to make sure the facility is doing its due diligence by the residents. Record review of facility policy, titled Abuse Prevention and Prohibition Program dated 10/24/2022, revealed the following: .VI. Investigation.H. Resident-to-resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain.i. The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate on non-accidental behavior.ii. Assessing psychosocial outcome of the victim of abuse may be difficult to determine or incongruent with what would be expected. In these situations, the Investigator should consider how a reasonable person in the resident's circumstances would be impacted by the incident.IX. Reporting/Response.D. The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime.i. Immediately, but no later than 2 hours after forming the suspicion if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).ii. No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman (if applicable per state regulation).iii. Reporting requirements are based on real (clock) time, not business hours.iv. The Administrator will provide the state survey agency, law enforcement and the Ombudsman (if applicable per state regulation) with a copy of the investigative report within 5 days of the incident.Record review of Long-Term Care Regulation Provider Letter, date issued 10/29/2024, revealed the following: Abuse:HHSC rules define abuse as:‘The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault.'14CMS defines abuse as:‘The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.'15Note: Allegations or incidents of resident-to-resident behavior may or may not meet the definition of abuse depending on whether a resident acted willfully. As the CFR states: ‘Willful, as used in the definition of 'abuse,' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.'16 455494 Page 4 of 6 455494 11/19/2025 Glenview Wellness & Rehabilitation 7625 Glenview Dr North Richland Hills, TX 76180

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for quality of care.The facility failed to ensure Resident #1's weekly skin assessment was completed on 10/17/2025. This failure could place residents at risk of not identifying skin breakdown or injuries, and delayed treatment and monitoring. Findings included:Record review of Resident #1's admission record, dated 10/21/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of vascular dementia (a type of dementia caused by reduced blood flow to the brain). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Record review of Resident #1's care plan, dated initiated 10/10/25, revealed Resident #1 was the receiver of aggression from another resident and sustained injury to the skin as noted in skin injury care plan. Interventions included the following: - Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document.- Assess and address for contributing sensory deficits- Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.- Monitor resident frequently. Document observed behavior and attempted interventions in behavior log.- Separate from potential resident to resident incidents. Take to another area away from resident or residents to calm down and keep safe. If needed, [Health Company Name] eval/treat.Record review of Resident #1's weekly skin check, dated 10/10/2025 at 11:04 PM, revealed bruise to left forearm / skin tear to back of right hand.Record review of Resident #1's EHR revealed no weekly skin checks completed since 10/10/2025 . Record review of MAR and TAR for October 2025 revealed the following:- Cleanse left arm with normal saline, pat dry, apply TAO, LOTA every day shift for skin treatment for 10 Days -Order Date-10/14/2025 - D/C Date-10/21/2025- Monitor bruise to left forearm until resolved every shift for Infection prevention -Order Date-10/10/2025 - D/C Date-10/21/2025Monitor skin to right hand until resolved every shift for Infection prevention - Order Date-10/10/2025 Record review of Resident #1's incident report, dated 10/10/2025 at 8:00 PM, completed by LVN B, revealed Incident Description.Pt walking down the hallway from her room holding her left forearm with blood noted on shirt, skin tear to right hand and nonintact skin noted to left forearm. Resident unable to give description. Unwitnessed. Immediate Action Taken.head to toe skin assessment, pain assessments, trauma assessed. Notified MD, RP, separated resident from roommate.Injuries observed at Time of Incident: Injury type Abrasion on left forearm and Bruise right hand (back). Level of Pain: 0.Interview on 10/21/2025 at 3:30 PM, LVN B stated he did a full skin assessment on Resident #1 and an incident report later that night after she had calmed down on 10/10/2025. He stated he did not see any bruises on the upper right arm when he assessed her. LVN B stated he was not aware of any current bruises on Resident #1's upper right arm. When asked who was supposed to do the next skin assessment LVN B did not know. LVN B stated it just pops up in the system and it will prompt you. LVN B did not give a reason why the weekly skin assessment was not completed on 10/17/25. Interview on 10/21/2025 at 3:53 pm, ADON C stated she was not aware of the bruises on Resident #2's right upper arm. She stated LVN B would have been responsible to complete Resident #1's skin assessment on 10/17/2025. Interview on 10/21/2025 at 4:32 pm, the Administrator stated skin assessments should be completed weekly, depending on the resident. She stated the nurse was responsible for completing assessments and the ADON and DON were responsible for monitoring they were completed. She stated the risk to residents if not done was they were left unmonitored, they could have an adverse injury, or reaction. Interview on 10/22/2025 at Residents Affected - Few 455494 Page 5 of 6 455494 11/19/2025 Glenview Wellness & Rehabilitation 7625 Glenview Dr North Richland Hills, TX 76180

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9:14 am, the Corporate Nurse stated they did not have a weekly skin assessment policy. She stated skin assessments should be completed weekly and if the resident refused, then documentation of the refusal. Interview on 10/22/2025 at 10:17 am, the DON stated Resident #1's skin assessment should have been completed on 10/17/2025 by LVN B. She stated the risk to residents was missing or preventing skin breakdown and safety. She stated they would need to be aware of the bruise and monitor, make sure it was not getting bigger or not resolved. 455494 Page 6 of 6