Health inspection·July 16, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few were notified of resident's statements. IDT was already aware of situation, resident assessments have been initiated. Other male resident has been placed on 1 on 1 supervision.SSD, SS Assistant and BOM spoke at length with [Resident #1] due to him being worked up stating ‘The police are going to have to be called on me because I am going to take care of him for doing this. I don't care about going to jail.' [Resident #1] was educated on treating others the way he wants to be treated, facility rules for no aggression, what jail is like, how expensive it is to bond out, how much a fine could be, that this behavior would interrupt his desire to eventually move to another facility.Due to resident stating understanding in one breath and then returning to being worked up, [Psych NP] was notified. NP then spoke with Hallway Nurses where PRN Anxiety [sic] med Dr. Order was written.-the SSD on 07/11/25 at 4:17 PM wrote: SSD called [City Initials] PD Non-Emergency [phone number] and requested that a Patrol Unit be dispatched to [Facility Name] to meet with [Resident #1] in an attempt to speak with him, to get him to calm down after the physical altercation that he was in with another male resident yesterday. Interview on 07/16/25 at 8:45 AM with Resident #1 revealed he was lying in his bed watching TV. Resident #1 said Resident #2 was on the ground the other day and he was telling him he needed to get up. Resident #1 said he tried to help Resident #2 get up from the ground and then someone near them started talking back about something. Resident #1 said he turned his face to tell the other resident to be quiet and when he turned back to Resident #2, he punched him on the right side of his face. Resident #1 said it hurt and he was very upset about the situation, but he had calmed down since then. Resident #1 said he got a scratch on his face and had a bruise for a few days but it had since healed. Resident #1 said he felt safe in the facility and was not afraid of Resident #2. Resident #1 did not have any bruises or cuts to either side of his face. Review of Resident #2's admission Record, dated 07/15/25, reflected he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE].Review of Resident #2's Quarterly MDS Assessment, dated 05/06/25, reflected he did not have a BIMS score calculated. It was noted that Resident #2 had both short-term and long-term memory problems and had severely impaired cognitive skills for daily decision making. Resident #2's behaviors towards others included physical and wandering that had occurred for 1 to 3 days. His active diagnoses included Alzheimer's disease (a neurological disorder that slowly destroys memory and thinking skills, and the ability to carry out the simplest task), a stroke (happens when something prevents your brain from getting enough blood flow), non-alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problem's in one's abilities to perform daily tasks), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and schizophrenia (a chronic mental health condition that affects how individuals think, feel, and behave).Review of Resident #2's undated care plan did not reflect anything related to the incident on 07/10/25.Review of Resident #2's Psych Visit Note, dated 07/14/25, reflected the following: The patient is being seen today for reevaluation of mood and to assess the need for ongoing 1:1 observation. Staff do not report and concerns [sic] or complaints. The patient has not had any aggressive behaviors for >48 hours.The patient is calm and nonverbal during today's encounter. Due to limited communication, he is unable to elaborate on thoughts or emotions or engage in meaningful conversation. There are no observable signs of sadness, depression, anxiety, panic, anger, or mood instability. No impulsive or aggressive behaviors were noted. There is no evidence of manic symptoms or perceptual disturbances. He is not exhibiting any behaviors or attitudes to suggest he poses a danger to himself or others. Based on observation, staff report, and chart review, the patient appears to be at his mental and emotional baseline and remains stable on the current treatment regimen. The case was discussed with the treatment team, and the decision was made to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455606 If continuation sheet Page 2 of 4 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 455606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Care Center 3301 View St Fort Worth, TX 76103 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 - Actual harm Residents Affected - Few discontinue 1:1 observation.Review of Resident #2's Progress Notes reflected the following: -LVN C on 07/10/25 at 3:30 PM wrote: esident [sic] walking around the dining area and he hit [Resident #1] around the circle of the left eye, Resident separated and moved to his room and was assessed and noted no apparent injuries.The NP notified with new order to continue to monitor resident for altercation. The DON notified and [Resident #2's Family Member] notified. Resident not able to state what happened or how he hit the other resident when asked by this writer.Resident [sic] deniespain [sic] and discomfort.-RN D on 07/11/25 at 3:56 AM wrote: The resident is in bed resting. No distress or behavior noted on this shift.-LVN C on 07/11/25 at 11:02 PM wrote: Resident continue [sic] on 1:1 monitoring and resting quietly in bed.-RN D on 07/12/25 at 2:35 AM wrote: Ln [sic] bed resting. No behavior noed. [sic]-RN D on 07/13/25 at 2:43 AM wrote: The resident is on 1:1 monitoring for behavior. No behavior is noted at this time.-LVN E on 07/14/25 at 4:59 AM wrote: The resident continue [sic] on 1:1 monitoring for aggressive behavior, staff at the bedside, no behavior reported.Observation and attempted interview on 07/16/25 at 8:55 AM of Resident #2 revealed he was laying in his bed. Resident #2 was not able to answer any questions due to his condition as he just stared blankly at the surveyor. Interview on 07/15/25 at 3:21 PM with LVN A revealed he was at the nurse's station when he heard a noise and an ADON told him that's your patient so he went to find out what had happened. LVN A said by the time he got there, Resident #1 was explaining what happened but that he did not do anything to him. LVN A said he took Resident #1 away from the area and tried talking to him and telling him that Resident #2 did not know what he was doing or had done. LVN A said Resident #2 was placed on 1:1 since he wandered around the facility, and he stayed with Resident #1 for a while to make sure he was okay and calm. LVN A said Resident #1 was punched by Resident #2 and had suffered a little scratch to his face from it. LVN A said staff kept their eyes on Residents #1 and #2 after this. LVN A said he had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 9:28 AM with LVN C revealed she cared for Resident #2 who was very confused and wandered around the facility. LVN C said Resident #1 told her that Resident #2 had punched him in the dining room. LVN C said she redirected Resident #1 back to his room and tried to keep him calm since he was upset from the incident. LVN C said she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 9:35 AM with LVN F revealed she cared for Resident #1 the next day and saw that his face was a little discolored on one side and was red. LVN F said he did not have any pain but did have a scratch to his face which did not require any treatment. LVN F said Resident #1 was very upset about the situation and needed to be calmed down. LVN F said she assured Resident #1 that Resident #2 would be kept away from him as he was being watched closely by staff. LVN F said she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 10:37 AM with the ADON revealed she heard yelling in the dining room and when she went down there to see what happened, Resident #1 told her that Resident #2 had hit him. The ADON said the residents were separated away from each other and she saw that Resident #1 had a small scratch on his cheek that did not require treatment. The ADON said she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 12:13 PM with the DON revealed Resident #1 was agitated but could be calmed down with redirection. The DON said Resident #2 had a BIMS of 0 and had no idea what happened and could not even say his name. The DON said Resident #2 hit Resident #1 who became very angry about what happened. The DON said both residents were separated from each other and Resident #2 was placed on 1:1 until the psych doctor could come and evaluate him. The DON said Resident #1 had a scratch to his face but that was his only injury. The DON said all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455606 If continuation sheet Page 3 of 4 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 455606 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Care Center 3301 View St Fort Worth, TX 76103 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete staff were in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 1:50 PM with the Administrator revealed Resident #2 was sitting on the floor, and which he was already care planned for that behavior. The Administrator said Resident #1 had leaned over and extended his hand to Resident #2 when another resident began to [NAME] the residents and make a lot of noise. The Administrator said Resident #2 was startled by this and reacted by striking Resident #1 on the face and mouth area. The Administrator said Resident #2 was upset by this and both residents were separated. The Administrator said Resident #2 walked away as if nothing had happened, but he was placed on 1:1 because he liked to wander. The Administrator said Resident #1 was very upset about the situation and would not let it go for days but has since calmed down. The Administrator said Resident #1 had a scratch to his lip but it had already healed since the incident happened. The Administrator said the facility completed safe surveys with other residents, in-serviced staff on abuse/neglect and resident-to-resident altercations. The Administrator said all residents had the right to be free from abuse and this situation was considered physical abuse. The Administrator said all staff had the responsibility to keep residents free from abuse. The Administrator said if residents were not free from abuse they could be fearful of others and this was their home and they should not be hurt by anyone.Review of the facility's provider investigation report, dated 07/15/25, reflected the following: Investigation Summary: [Resident #2] had no recollection of the incident immediately after the incident as the writer attempted to interview him. This same writer interviewed [Resident #1] who explained that he was trying to help [Resident #2] up from the ground and was hit on his cheek. When this writer asked him if another resident was yelling in the background, he stated he did not recall. This write informed him that [Resident #2] seemed to be startled by the other resident which may have caused him to hit [Resident #1]. [Resident #1] did not acknowledge if he understood or not. [Resident #2] does not have any negative outcome due to this incident. [Resident #2] initially was upset but seems much better now and continue s [sic] to participate in his normal activities.Facility Investigation Findings: Confirmed.Review of resident safe surveys, dated 07/11/25, revealed 12 were completed with no additional abuse allegations founded.Review of an in-service, titled Abuse and Neglect, dated 07/10/25, reflected 38 staff had been in-serviced.Review of the facility's policy, revised 09/06/24, and titled Abuse, Neglect and Exploitation reflected: III. Prevention of Abuse, Neglect and Exploitation.The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of property is suspected or identified by: 1. Taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to resident or other residents.IV. Identification of Abuse, Neglect and Exploitation A. The facility assists staff to understand the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This included staff to resident abuse and certain resident to resident altercations. Event ID: Facility ID: 455606 If continuation sheet Page 4 of 4