Health inspection·October 20, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual and physical abuse for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. Residents Affected - Few The facility failed to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area on 10/8/23. The facility failed to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear on 10/11/23. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for physical harm, psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse and Neglect - Clinical Protocol, revised 10/15/2022, revealed the following: Policy Statement The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation Different Abuse of any Types: . Resident to Resident Abuse of Any Type: o Altercations between residents should be reviewed as a potential situation of abuse. For example, infrequent arguments or disagreements that occur during the course of normal. Social interactions (e.g., dinner table discussions) would not meet the definition of abuse. Page 1 of 20 455673 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 o Level of Harm - Immediate jeopardy to resident health or safety Both residents having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. o Residents Affected - Few It is important to remember that abuse included the term willful which means that the individual'[s action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. If it is determined that the action was not willful (a deliberate action) that the facility is in compliance with the requirements to maintain an environment free of accident hazards as possible, and each resident receives adequate supervision . Definitions Abuse is defined at §483.5 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. Sexual abuse is defined at §483.5 as non-consensual sexual contact of any type with a resident. Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual activity. For any alleged violation of sexual abuse the facility will: a. Immediately implement safeguards to prevent further potential abuse; . Physical Abuse -this includes but is not limited to hitting, slapping, pinching, and kicking . Review of a facesheet for Resident #1, dated 10/10/2023, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including: cognitive communication deficit, dementia, severe major depressive disorder, and anxiety disorder. 455673 Page 2 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #1's MDS assessment, dated 08/10/2023, revealed she had a BIMSscore of 99, indicating severe impairment. Resident #1's functional status revealed she was non-ambulatory and required extensive assistance with one-person physical assist support for bed mobility, transfer, and dressing. Review of Resident #1's care plan, dated 10/09/2023, revealed she had goals to include symptoms of delirium will resolve without lasting effects; anxiety does not interfere with functional abilities; remains free from skin breakdown; with interventions to report changes in alertness or memory to doctor; assess for changes in mood status, assist in determine source of anxiety and precipitating events, allow to verbalize feelings, provide environment that respects privacy. Review of Resident #1's skin care alert, dated 10/08/2023, revealed she had scratches to right thigh and redness to perineal area (vaginal region below the pelvic diaphragm). Review of Resident #1's progress notes by treatment nurse, dated 10/09/2023, revealed skin assessment was completed and resident was noted with blanchable redness and scratches to peri area. Review of a face sheet for Resident #2, dated 10/10/2023, revealed he was an [AGE] year-old male, admitted on [DATE] and discharged to behavioral hospital on [DATE]. Resident #2's face sheet revealed he had diagnoses including depression, muscle weakness, and insomnia. Review of Resident #2's MDS assessment, dated 07/31/2023, revealed he had a BIMS score of 09, indicating moderate impairment. Resident #2's functional status revealed he required setup help only for locomotion on unit and bed mobility. Resident #2's behavior revealed he had no physical or wandering behavior. Review of Resident #2's care plan, dated 10/08/2023, revealed DON note that he had no history of behaviors while recievingpsychiatric services, a risk of side effects for antidepressant and hypnotic medication use, difficulty with sleeping with interventions to include monitor patterns of target behaviors, monitor and record sleep patterns, assess for adverse side effects, document and report, assess for changes in mood status, and provide environmental changes to facilitate sleep. Review of employee statement by CNA A, dated 10/08/2023, revealed the following: As I was making rounds I discovered (Resident #2) in (Resident #1)'s room with his hand placed in her diaper. I immediately yelled stop, get out, and never kept my eyes off of him. I yelled for the aide, and the med-aide down the hall. He backed his wheelchair up and went into his room to wash his hands. We immediately notified the nurse. Review of employee statement by MA E,dated 10/08/2023, revealed the following: As I came down the hall to assist (CNA A) was in (Resident #1) room and (Resident #2) exiting to go into his room and began to wash his hands and nurse was immediately notified. Review of employee statement by LVN A, dated 10/08/2023, revealed the following: Assisting another resident to her room on 300 hall when called by (CMA A) to come to 200 hall. As going immediately to CNA, informed by her that (Resident #2) was seen in (Resident #1)'s room fondling her. It was then reported that (Resident #2) was seen going back to his room and was washing his hands. Immediately started walking down hallway and observed (Resident #2) washing his hands at sink in room. (Resident #1) checked on and she appeared to be visibly upset. Crying and very emotional. Inquired from her if anyone came to room and she was unable to state anything. (Normal behavior). Immediately called 455673 Page 3 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ADON and reported incident to her. ADON stated she was calling administrator. Went to question (Resident #2) about incident. Inquired if he went across hallway and was touching someone inappropriately. He stated that he did touch her. Asked if this was first time doing this in which he denied doing it before. (Witness CNA A present when admitted to touching her) management then placed (Resident #2) on one-on-one. Review of Resident #2's progress notes by RN A, dated 10/08/2023 at 4:00 p.m., revealed CNA reported to RN A that resident was in a female resident's room at bedside with his hand in her brief and he was immediately removed from her room and assisted back to his room. Review of Resident #2's progress notes by DON, dated 10/08/2023 at 7:00 p.m., revealed investigation into allegation of abuse was opened. (RP A) was contacted and spoke with administrator, police Officer A, and Officer B present. Responsible party and resident consented to referral to behavioral hospital for evaluation. Resident assessment revealed he was awake, alert, and answered questions without signs of emotional distress and resident denied incident occurred. Resident was on one-to-one monitoring by staff until transfer. Review of Resident #2's progress notes by LPN A, dated 10/09/2023 at 12:32 p.m., revealed resident was transferred to behavioral hospital and no behaviors were noted. Review of in-service provided by DON, dated 10/08/2023, revealed education was provided on abuse and neglect with the following objectives: recognizing abuse, reporting abuse, resident safety, and seven components of abuse. Review of in-services, dated 10/08/2023, revealed education was provided to nursing staff on recognizing and reporting abuse, resident safety, seven components of abuse, and elder sexual abuse and warning signs and included the following: Sexual abuse of an elderly person occurs when a caregiver or another person forces unwanted sexual contact or penetration with an elderly person. Older adults are especially vulnerable to perpetrators of sexual abuse. Perpetrators target individuals who they perceive are vulnerable or easy to overpower. They also abuse elders who they think are unlikely to report the abuse or be believed. Elder sexual abuse can include: sexual contact with an elderly person who is confused or unable to give consent sexual contact or penetration without the victim's consent forced nudity photographing a person in a sexual way without that person's consent Some elderly victims are unable to give consent due to health conditions, such as dementia or Alzheimer's disease. Elderly women are much more likely to be abused than elderly men. Most reports of older sexual abuse come from nursing homes . Review of Resident #2 behavioral hospital interdisciplinary notes and labs, dated 10/09/2023 and 10/10/2023, revealed he was admitted on [DATE] for inappropriate behavior. Interdisciplinary notes 455673 Page 4 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety revealed resident was sent from nursing facility and had no history of sexual, physical, or emotional abuse. Interdisciplinary notes revealed he has insomnia and does not sleep well at night. This patient lacks insight and judgment is poor. This patient behavior was inappropriate, and he is a danger to others. Labs revealed he had no indication for a urinary tract infection. Review of police report, dated 10/17/2023, revealed the following narrative by Officer A: Residents Affected - Few On October 8, 2023, at around 4:40 PM, (Officer A) was dispatched to (facility name and address) nursing home for a sexual assault report. On scene, (Officer A) spoke with nursing staff and witness, (CNA A), who stated that as she was walking down the hallway and passing room (Resident #1's room number), she observed (Resident #2) with his hand down the front of the incontinence diaper of [NAME] Doe. (CNA A) said she confronted (Resident #2) and he yelled at her and swung at her then wheelchaired himself out of the room, across the hallway to his room (Resident #2's room number). Staff nurses interviewed [NAME] Doe in the presence of (Officer A) and she had no recollection of anyone coming in her room and stated she did not have any pain or discomfort to report. [NAME] Doe is a [AGE] year-old female with severe cognitive impairment. (Forensic interviewer) was contacted to determine of SANE exam was necessary and to schedule it if so. (Forensic interviewer) stated that due to mental status of both parties, that a SANE exam did not seem necessary. (Forensic interviewer) and (Officer A) believed it best to contact [NAME] Doe's [family member], (RP A), to ask whether he wanted to pursue charges given the circumstances. (RP A) told (Officer A) that he did not believe charges were necessary and that the steps the nursing home was taking to move (Resident #2) to another location were sufficient. (Officer A) next contact Adult Protective Services (APS) to inform them of the situation and obtain a reference number . Review of police report, dated 10/08/2023, revealed the following supplement by Officer B: (Officer B) arrived at (facility name and address) in regard to a sexual assault report. (Officer B) spoke with witness, (CNA A). She stated she walked into room (Resident #1's room number) at approximately 1600 hours [4:00 PM] and observed (Resident #2) sitting on [NAME] Doe's bed with [NAME] Doe laying down. (CNA A) stated she observed his hand in the side of [NAME] Doe's diaper and when she made her presence known, (Resident #2) removed his hand quickly and exited her room. (Officer B) then went with complainant, (ADON), to question (Resident #2). (Resident #2) stated he did not enter the room he just went to the doorway to speak with [NAME] Doe. (Resident #2 denied any sexual involvement with [NAME] Doe and advised he was too old to be doing sexual things. (ADON) advised (Resident #2) has a moderate cognitive impairment . Review of Provider Investigation Report, dated 10/08/2023, revealed the administrator was notified by ADON of the sexual abuse incident between Resident #1 and Resident #2 with one witness, CNA A. Police, both residents' responsible parties, and medical director was contacted. The responsible party of Resident #1 declined the offer of being sent out for SANE (Sexual Assault Nurse Examiner) exam and hospital for evaluation. The responsible party also declined the same offer from Officer A. Resident #1's room is directly across from Resident #2. One on one with Resident #2 was performed until discharges to behavioral hospital on [DATE] with alternative placement recommended. Full body assessment was performed by ADON on Resident #1 with findings of redness to peri area. Safe surveys were performed on all residents with no concerns to ensure no other residents were involved or had contact with Resident #2 and safe surveys will continue weekly times 4. Staff in-serviced abuse, neglect, and sexual abuse in the elderly. During an interview on 10/12/2023 at 12:13 p.m., the administrator, DON, and ADON said the sexual 455673 Page 5 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few abuse allegation incident occurred on 10/08/2023 at 3:45 p.m. CNA A witnessed the incident and LVN A was notified and assessed residents. The administrator said she was the abuse coordinator and when interviewed Resident #2 denied close contact with Resident #1. The administrator said Resident #2 was placed on one-to-one monitoring until he was sent to a behavioral hospital on [DATE]. The administrator said Resident #2 was not anticipated to return. The administrator said Resident #1 was smiling and in no distress during her interview following the incident and Resident #1 reported no harm and did not remember event. The administrator said police were notified and interviewed residents on-site. The administrator said to prevent further abuse Resident #2 received one-to-one monitoring until he was discharged to behavioral hospital, safe surveys and skin assessments were completed on all residents by 10/09/2023, and staff received in-services on sexual abuse completed 10/09/2023 and safe surveys will continue weekly times 4 weeks. The administrator said she had an additional self-report recently submitted to HHSC. During an interview and observation on 10/12/2023 at 1:43 p.m., Resident # 1 was sitting in her geriatric chair in common lobby area near nursing station. Resident #1 said everyone was nice to her and that she was doing good and had no concerns. Resident #1 appeared pleasant, free from apparent injury, and in no distress. During an interview on 10/12/2023 at 2:40 p.m., CNA B said she was not at the facility during the incident with Resident #1 and Resident #2 but that she normally takes care of Resident #2. CNA B said that if she witnessed a male resident with his hand in a female residents brief she would immediately get the charge nurses. CNA B said Resident #2 had no inappropriate behavior under her care and would have never thought he would have sexually abused a resident. CNA B said Resident #1 is crying and emotional at baseline and that they do not normally interact. CNA B said she did not talk with either resident about what happened and that residents have been getting along. CNA B said to prevent abuse the facility has provided in-services on abuse. During an interview on 10/12/2023 at 3:01 p.m., CNA C said she had been employed at the facility for 10 years and did not take care of Resident #1 or Resident #2. CNA A said she arrived to the facility during reporting of the incident and was aware that Resident #2 was reported to have been fondling Resident #1. CNA C said she felt that residents are safe and that there were no other residents involved with Resident #2 because she knew a majority of the residents for a long time when they were at the old facility building. During an interview on 10/12/2023 at 3:11 p.m., LVN C said she had been employed at the facility for 13 years and normally cares for Resident #1 and Resident #2. LVN C said Resident #1 was pleasant today and sometimes cries for unknown reasons at baseline. LVN C said Resident #2 had never had any history of inappropriate behavior. LVN C said she was not working when the event occurred, but that Resident #2 was sent to the behavioral hospital and will not be coming back. LVN C said there was an additional fight since incident between two residents and that it was behavior on aggressors' part, and he was also sent to a behavioral hospital. LVN C said she felt that residents are safe with those two residents out of the facility. LVN C said Resident #4 went into Resident #3's room and accused him of laying in his bed, but he was not in his right room. LVN C said she was taking care of Resident #3 and that he was doing good and had no changes in his mood or behavior. Review of a facesheet with no date and admission MDS , dated 08/24/2023, for Resident #3 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: dementia with other behavioral disturbance, major depressive disorder, cognitive communication deficit, muscle weakness, and intermittent explosive disorder. 455673 Page 6 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Review of MDS, dated [DATE], for Resident #3 revealed he had a BIMS score of 13, indicating he was cognitively intact and functional status revealed he was non-ambulatory. Review of care plan dated 10/12/2023, for Resident #3 revealed the resident has limited physical mobility related to dementia with a goal to remain free from complications of skin breakdown to include interventions of wheelchair use for locomotion. Residents Affected - Few Review of a facesheet with no date and admission MDS, dated [DATE], for Resident #4 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: Parkinson's disease, psychotic disorder with delusions and hallucinations due to known physiological condition, schizoaffective disorder, bipolar type, dementia, insomnia, and recurrent depressive disorders. Review of MD notes, dated 09/28/2023, for Resident #4 revealed his psychiatric affect and mood were appropriate and that he was cooperative with care. MD notes revealed his current plan of care and medications were continued as ordered and to notify of any changes. Review of MDS for Resident #4, dated 10/12/2023, revealed Resident #4 had a BIMS score of 05, indicating severe cognitive impairment. Review of care plan for Resident #4, dated 10/11/2023, revealed he had a focus including Parkinson's disease and psychotropic medication use with goals for him to remain free of further signs and symptoms, discomfort, or complications related to Parkinson's disease and psychotropic drug use through review date. Care plan interventions for Resident #4 included to monitor/document /report any signs and symptoms of medication side effects such as dizziness, somnolence, insomnia, confusion, and any targeted behavior such as violence/aggression towards staff and others. Review of progress notes dated 10/11/2023, for Resident #3 revealed resident had a physical altercation with another male resident who entered his room while he was laying in the bed. Progress notes revealed that Resident #3 reported, he came into my room, and I asked him to get out, but he wouldn't leave. He told me that l was in his room in his bed! I told him no I was in my bed, and he needed to leave. He came and started to hit me, and I hit him back. Progress notes revealed Resident #3 had a laceration to his nose and a bruise to his left ear and received an order for x-ray of facial bones. Progress notes revealed staff attempted to notify RP B and a message was left by staff on his voicemail. Progress notes revealed resident was resting in bed without distress post incident, first aid provided, and that staff would continue to observe. Progress notes revealed Resident #3 refused transfer to emergency room for evaluation and treatment and left ear was swollen and reddish/purple in color. Review of Skin Observation Worksheet signed by the DON, dated 10/11/2023, revealed Resident #3 had a bloody nose, skin split to bridge of nose, red edema, and a possible scratch behind his left ear. Review of x-ray of facial bones report, dated 10/12/2023, revealed Resident #3 had no significant findings. Review of progress notes, dated 10/11/2023, revealed Resident #4 was involved in a physical altercation with another male resident. Progress notes revealed Resident #4 was noticed at 200 hall exit door and then entered another resident's room at the end of that small hallway. The resident room he entered then activated the call light for assistance with getting him out of his room and told 455673 Page 7 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #4 several times to get out of his room. Progress Notes revealed Resident #4 then became angry telling Resident #4 to get out of my bed. Progress notes revealed Resident #4 then hit Resident #3 in his nose and ear causing his nose to bleed. Progress notes revealed Resident #4 continued to swing at nursing staff when removing him from room. Progress notes revealed Resident #4 continues to have increased anxiety, uncooperative with redirection, and residents family member was informed. Progress notes revealed staff approached Resident #4 to interview him on alleged incident and he was noted to be sitting up in wheelchair in doorway of room, agitated, verbally aggressive, and had attempted to swing his fists at staff members in the hallway who were standing outside doorway of resident room. Progress notes revealed staff approached him in calm, friendly voice and asked what was going on and resident stated nothing. Progress notes revealed that when asked if he hit another resident, Resident #4 stated, Yes, I went down there. I started hitting him. Progress Notes revealed he then began to mumble and was incomprehensible. Progress notes revealed Resident #4 had unclear and unintelligible speech at times and MD was notified new order was received to transfer resident to behavioral hospital. Review of witness statement by CNA D, dated 10/11/2023, revealed she went to answer the call light for Resident #3's room and found Resident #4 in the room with Resident #3. Witness statement revealed residents were fighting and CNA D tried to break it up when Resident #4 turned and began trying to fight her. Witness statement revealed CNA D then told her coworker to get the nurse. Review of witness statement by CMA B, with no date, revealed the following: We were at the nurse's station. A staff ran up and said two men residents are fighting. One of the residents got CNA D blocked in the room. Two nurses and I ran down the hall to the last room. We walked in the room. It was (Resident #3)'s room and his nose was red and bleeding. Nurse asked him what happened because he was laying in the bed bleeding. He said he hit me in the nose. (Resident #4) had hit him. Staff removed (Resident #4). He was still trying to fight. Another nurse helped and took care of (Resident #3)'s nose. Review of witness statement by LVN D, dated 10/11/2023, revealed the following: This nurse was at the nurse's station when CNA's called for me to come down the hall because two residents were having an altercation. Upon arrival to (Resident #3's) room this nurse observed (CNA D) trying to remove (Resident #4) from the room. (Resident #4) was being combative and very upset. (Resident #3) is noted to be bleeding from his nose and all down his face. A laceration is noted to the left side of (Resident #3's) nose and a bruise to his left ear. (Resident #3) reports that he asked (Resident #4) to get out of his room and (Resident #4) hit him telling him this was his room and he needed to get out of his bed. (Resident #3) reports that he hit him back defending himself. (Resident #4) is up the hallway with other staff at this time. (Resident #3) denies any pain. No distress noted. Review of employee statement by LVN B, dated 10/11/2023, revealed the following: This nurse was walking up toward 100 hall when I saw staff members rushing towards (Resident #3's room). I brought coffee to a resident and then started down 200 hall. I saw the resident (Resident #4) being wheeled out of the (Resident #3) room by a staff member. He was swinging trying to hit her. The resident had hit another resident (Resident #3's room number) in the face and ear causing that resident's nose to bleed. This nurse cleaned the blood off the resident (Resident #3). (Resident #4) also tried to hit various other staff members. 455673 Page 8 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of provider investigation report with no date revealed Resident #3 and Resident #4 had an altercation on 10/11/2023 at 1:10 p.m. witnessed by CNA D. The brief narrative summary of report revealed Resident #4 entered Resident #4's room and an argument ensued resulting in physical aggression with each other. Assessment details of report revealed Resident #4 struck Resident #4 in the nose leading to epistaxis (nosebleed), bruising, and edema to left ear and Resident #4 had superficial scratch to this face left of nose with no other injuries noted. Assessment details revealed Resident #4 was referred for a psychiatric evaluation at behavioral hospital and Resident #4 assessments to be completed every shift to monitor for emotional distress. Actions and Notifications section revealed MD, both RP's, administrator, and DON were notified, and staff in-services were conducted on resident-to-resident violence and de-escalation of situation, reporting, and abuse and neglect. Provider investigation report revealed one on one supervision with Resident #4 was completed on 10/11/2023 and 10/12/2023. Review of Provider Investigation Report by DON, with no date, revealed resident-to-resident altercation incident between Resident #3 and Resident #4 occurred on 10/11/2023 at 1:10 p.m. Provider Investigation Report revealed in-services were provided to staff on resident-on-resident violence and de-escalation of situation, reporting, abuse and neglect. Review of progress notes for Resident #4, dated 10/12/2023, revealed he continued to be combative with staff during transport to behavioral hospital and driver had to pull over and contact EMS. During an interview on 10/12/2023 at 4:07 p.m., LVN A said she was taking a resident back to her room on 10/08/2023 and heard the aide yell for her. LVN A said they started walking down the hall to the aide and Resident #2 was seen with his hand in Resident #1's brief and was then seen in his room washing his hands. LVN A said Resident #1 was crying and upset but she was not able to say what happened. LVN A said she notified ADON immediately and the administrator and protected Resident #1 until they arrived. LVN A said when she asked Resident #2 at first, he denied the incident then later when asked he said, Yeah, I did it. LVN A said she asked Resident #2 if he did it before and he said no it was the first time. LVN A said Resident #2 kept trying to avoid that question. LVN A said she assessed Resident #1, obtained her vital signs, took a picture of the brief before they took it off and looked at the skin in that brief area and she had a very little fingernail width scratch to the right side and if you dab it with a wet cloth it had a drop of blood on it so it was fresh and from what LVN A saw it did appear he assaulted her due to her scratch in area and because she blurted out don't put it in there which was not normal for her to say. LVN A said CNA A told her she saw Resident #2 with his hand in Resident #1's brief and CMA A was the aide that came to the 200 hall calling her name. LVN A said Resident #2 had no history of inappropriate behavior since she has been employed in April 2023 and that their rooms were directly across from each other. LVN A said the resident had a roommate but that it appeared Resident #2 shut that curtain in her room because the curtain was pulled all the way to the end of the bed. LVN A said the incident happened on Sunday, 10/8/23, and that she had taken care of Resident #1 following the incident and appeared at baseline in no distress. LVN A said the facility put interventions in place to protect the resident and prevent sexual abuse from occurring by placing Resident #2 on one-on-one monitoring until he was discharged , frequent 30 minute checks on Resident #1, police were notified and investigated on-site, and staff had received a couple of in-services on different kinds of abuse and neglect following the incident. LVN A said she had no concerns with any other residents showing signs of sexual abuse. During an interview on 10/13/2023 at 9:27 a.m., CNA A said the administrator was the abuse coordinator. CNA A said she was coming out of hall on 10/08/2023 around 3:45 p.m. to do her rounds and Resident #2 was in Resident #1's room with his hand in her brief and she told him to stop and yelled for 455673 Page 9 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few two aides to assist. CNA A said Resident #1 was crying and Resident #2 backed his wheelchair in the other room and started washing his hands. CNA A said Resident #2 did not say what he was doing and that she suspected sexual abuse. CNA said the nurse called and notified someone to let them know it happened and did a skin assessment. CNA A said the brief was open and appeared it had been messed with. CNA A said Resident #1 was doing fine now at baseline and does not remember what happened. CNA A said the nurse called the responsible party and let him know what happened and the police came the same day. Resident #2 had no behavior prior to this and had no behavior and did not know if this had happened before. CNA A said interventions were put in place to protect residents from further abuse by placing Resident #2 on one-to-one monitoring, moving Resident #2 to a behavioral hospital, and in-services were conducted on sexual abuse. CNA A said it was important to protect residents from any kind of sexual abuse because she would not[TRUNCATED] 455673 Page 10 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 2 of 9 residents (Resident #1 and Resident #3) reviewed for abuse. Residents Affected - Few The facility failed to implement policies and procedures to prevent sexual abuse for Resident #1 found crying in her room with Resident #2's hand under her brief in perineal area. The facility failed to implement policies and procedures to prevent physical abuse for Resident #3 that was hit in the face in his room by Resident #4 and sustained injuries to include a bloody nose, skin tear to left side of nose, and swelling to his left ear. The noncompliance was identified as PNC. The IJ began on 10/08/2023 and ended on 10/12/2023. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for physical harm, psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse and Neglect - Clinical Protocol, revised 10/15/2022, revealed the following: Policy Statement The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation Different Abuse of any Types: . Resident to Resident Abuse of Any Type: o Altercations between residents should be reviewed as a potential situation of abuse. For example, infrequent arguments or disagreements that occur during the course of normal. Social interactions (e.g., dinner table discussions) would not meet the definition of abuse. o Both residents having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. o 455673 Page 11 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few It is important to remember that abuse included the term willful which means that the individual'[s action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. If it is determined that the action was not willful (a deliberate action) that the facility is in compliance with the requirements to maintain an environment free of accident hazards as possible, and each resident receives adequate supervision . Definitions Abuse is defined at §483.5 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. Sexual abuse is defined at §483.5 as non-consensual sexual contact of any type with a resident. Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps should include evaluating whether the resident has the capacity to consent to sexual activity. For any alleged violation of sexual abuse the facility will: a. Immediately implement safeguards to prevent further potential abuse; . Physical Abuse -this includes but is not limited to hitting, slapping, pinching, and kicking . Review of a facesheet for Resident #1, dated 10/10/2023, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including: cognitive communication deficit, dementia, severe major depressive disorder, and anxiety disorder. Review of Resident #1's MDS assessment, dated 08/10/2023, revealed she had a BIMSscore of 99, indicating severe impairment. Resident #1's functional status revealed she was non-ambulatory and required extensive assistance with one-person physical assist support for bed mobility, transfer, and dressing. Review of Resident #1's care plan, dated 10/09/2023, revealed she had goals to include symptoms of 455673 Page 12 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few delirium will resolve without lasting effects; anxiety does not interfere with functional abilities; remains free from skin breakdown; with interventions to report changes in alertness or memory to doctor; assess for changes in mood status, assist in determine source of anxiety and precipitating events, allow to verbalize feelings, provide environment that respects privacy. Review of Resident #1's skin care alert, dated 10/08/2023, revealed she had scratches to right thigh and redness to perineal area (vaginal region below the pelvic diaphragm). Review of Resident #1's progress notes by treatment nurse, dated 10/09/2023, revealed skin assessment was completed and resident was noted with blanchable redness and scratches to peri area. Review of a face sheet for Resident #2, dated 10/10/2023, revealed he was an [AGE] year-old male, admitted on [DATE] and discharged to behavioral hospital on [DATE]. Resident #2's face sheet revealed he had diagnoses including depression, muscle weakness, and insomnia. Review of Resident #2's MDS assessment, dated 07/31/2023, revealed he had a BIMS score of 09, indicating moderate impairment. Resident #2's functional status revealed he required setup help only for locomotion on unit and bed mobility. Resident #2's behavior revealed he had no physical or wandering behavior. Review of Resident #2's care plan, dated 10/08/2023, revealed DON note that he had no history of behaviors while recievingpsychiatric services, a risk of side effects for antidepressant and hypnotic medication use, difficulty with sleeping with interventions to include monitor patterns of target behaviors, monitor and record sleep patterns, assess for adverse side effects, document and report, assess for changes in mood status, and provide environmental changes to facilitate sleep. Review of employee statement by CNA A, dated 10/08/2023, revealed the following: As I was making rounds I discovered (Resident #2) in (Resident #1)'s room with his hand placed in her diaper. I immediately yelled stop, get out, and never kept my eyes off of him. I yelled for the aide, and the med-aide down the hall. He backed his wheelchair up and went into his room to wash his hands. We immediately notified the nurse. Review of employee statement by MA E,dated 10/08/2023, revealed the following: As I came down the hall to assist (CNA A) was in (Resident #1) room and (Resident #2) exiting to go into his room and began to wash his hands and nurse was immediately notified. Review of employee statement by LVN A, dated 10/08/2023, revealed the following: Assisting another resident to her room on 300 hall when called by (CMA A) to come to 200 hall. As going immediately to CNA, informed by her that (Resident #2) was seen in (Resident #1)'s room fondling her. It was then reported that (Resident #2) was seen going back to his room and was washing his hands. Immediately started walking down hallway and observed (Resident #2) washing his hands at sink in room. (Resident #1) checked on and she appeared to be visibly upset. Crying and very emotional. Inquired from her if anyone came to room and she was unable to state anything. (Normal behavior). Immediately called ADON and reported incident to her. ADON stated she was calling administrator. Went to question (Resident #2) about incident. Inquired if he went across hallway and was touching someone inappropriately. He stated that he did touch her. Asked if this was first time doing this in which he denied doing it before. (Witness CNA A present when admitted to touching her) management then placed (Resident #2) on one-on-one. 455673 Page 13 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #2's progress notes by RN A, dated 10/08/2023 at 4:00 p.m., revealed CNA reported to RN A that resident was in a female resident's room at bedside with his hand in her brief and he was immediately removed from her room and assisted back to his room. Review of Resident #2's progress notes by DON, dated 10/08/2023 at 7:00 p.m., revealed investigation into allegation of abuse was opened. (RP A) was contacted and spoke with administrator, police Officer A, and Officer B present. Responsible party and resident consented to referral to behavioral hospital for evaluation. Resident assessment revealed he was awake, alert, and answered questions without signs of emotional distress and resident denied incident occurred. Resident was on one-to-one monitoring by staff until transfer. Review of Resident #2's progress notes by LPN A, dated 10/09/2023 at 12:32 p.m., revealed resident was transferred to behavioral hospital and no behaviors were noted. Review of in-service provided by DON, dated 10/08/2023, revealed education was provided on abuse and neglect with the following objectives: recognizing abuse, reporting abuse, resident safety, and seven components of abuse. Review of in-services, dated 10/08/2023, revealed education was provided to nursing staff on recognizing and reporting abuse, resident safety, seven components of abuse, and elder sexual abuse and warning signs and included the following: Sexual abuse of an elderly person occurs when a caregiver or another person forces unwanted sexual contact or penetration with an elderly person. Older adults are especially vulnerable to perpetrators of sexual abuse. Perpetrators target individuals who they perceive are vulnerable or easy to overpower. They also abuse elders who they think are unlikely to report the abuse or be believed. Elder sexual abuse can include: sexual contact with an elderly person who is confused or unable to give consent sexual contact or penetration without the victim's consent forced nudity photographing a person in a sexual way without that person's consent Some elderly victims are unable to give consent due to health conditions, such as dementia or Alzheimer's disease. Elderly women are much more likely to be abused than elderly men. Most reports of older sexual abuse come from nursing homes . Review of Resident #2 behavioral hospital interdisciplinary notes and labs, dated 10/09/2023 and 10/10/2023, revealed he was admitted on [DATE] for inappropriate behavior. Interdisciplinary notes revealed resident was sent from nursing facility and had no history of sexual, physical, or emotional abuse. Interdisciplinary notes revealed he has insomnia and does not sleep well at night. This patient lacks insight and judgment is poor. This patient behavior was inappropriate, and he is a danger to others. Labs revealed he had no indication for a urinary tract infection. Review of police report, dated 10/17/2023, revealed the following narrative by Officer A: 455673 Page 14 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On October 8, 2023, at around 4:40 PM, (Officer A) was dispatched to (facility name and address) nursing home for a sexual assault report. On scene, (Officer A) spoke with nursing staff and witness, (CNA A), who stated that as she was walking down the hallway and passing room (Resident #1's room number), she observed (Resident #2) with his hand down the front of the incontinence diaper of [NAME] Doe. (CNA A) said she confronted (Resident #2) and he yelled at her and swung at her then wheelchaired himself out of the room, across the hallway to his room (Resident #2's room number). Staff nurses interviewed [NAME] Doe in the presence of (Officer A) and she had no recollection of anyone coming in her room and stated she did not have any pain or discomfort to report. [NAME] Doe is a [AGE] year-old female with severe cognitive impairment. (Forensic interviewer) was contacted to determine of SANE exam was necessary and to schedule it if so. (Forensic interviewer) stated that due to mental status of both parties, that a SANE exam did not seem necessary. (Forensic interviewer) and (Officer A) believed it best to contact [NAME] Doe's [family member], (RP A), to ask whether he wanted to pursue charges given the circumstances. (RP A) told (Officer A) that he did not believe charges were necessary and that the steps the nursing home was taking to move (Resident #2) to another location were sufficient. (Officer A) next contact Adult Protective Services (APS) to inform them of the situation and obtain a reference number . Review of police report, dated 10/08/2023, revealed the following supplement by Officer B: (Officer B) arrived at (facility name and address) in regard to a sexual assault report. (Officer B) spoke with witness, (CNA A). She stated she walked into room (Resident #1's room number) at approximately 1600 hours [4:00 PM] and observed (Resident #2) sitting on [NAME] Doe's bed with [NAME] Doe laying down. (CNA A) stated she observed his hand in the side of [NAME] Doe's diaper and when she made her presence known, (Resident #2) removed his hand quickly and exited her room. (Officer B) then went with complainant, (ADON), to question (Resident #2). (Resident #2) stated he did not enter the room he just went to the doorway to speak with [NAME] Doe. (Resident #2 denied any sexual involvement with [NAME] Doe and advised he was too old to be doing sexual things. (ADON) advised (Resident #2) has a moderate cognitive impairment . Review of Provider Investigation Report, dated 10/08/2023, revealed the administrator was notified by ADON of the sexual abuse incident between Resident #1 and Resident #2 with one witness, CNA A. Police, both residents' responsible parties, and medical director was contacted. The responsible party of Resident #1 declined the offer of being sent out for SANE (Sexual Assault Nurse Examiner) exam and hospital for evaluation. The responsible party also declined the same offer from Officer A. Resident #1's room is directly across from Resident #2. One on one with Resident #2 was performed until discharges to behavioral hospital on [DATE] with alternative placement recommended. Full body assessment was performed by ADON on Resident #1 with findings of redness to peri area. Safe surveys were performed on all residents with no concerns to ensure no other residents were involved or had contact with Resident #2 and safe surveys will continue weekly times 4. Staff in-serviced abuse, neglect, and sexual abuse in the elderly. During an interview on 10/12/2023 at 12:13 p.m., the administrator, DON, and ADON said the sexual abuse allegation incident occurred on 10/08/2023 at 3:45 p.m. CNA A witnessed the incident and LVN A was notified and assessed residents. The administrator said she was the abuse coordinator and when interviewed Resident #2 denied close contact with Resident #1. The administrator said Resident #2 was placed on one-to-one monitoring until he was sent to a behavioral hospital on [DATE]. The administrator said Resident #2 was not anticipated to return. The administrator said Resident #1 was smiling and in no distress during her interview following the incident and Resident #1 reported no harm and did not remember event. The administrator said police were notified and interviewed residents 455673 Page 15 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few on-site. The administrator said to prevent further abuse Resident #2 received one-to-one monitoring until he was discharged to behavioral hospital, safe surveys and skin assessments were completed on all residents by 10/09/2023, and staff received in-services on sexual abuse completed 10/09/2023 and safe surveys will continue weekly times 4 weeks. The administrator said she had an additional self-report recently submitted to HHSC. During an interview and observation on 10/12/2023 at 1:43 p.m., Resident # 1 was sitting in her geriatric chair in common lobby area near nursing station. Resident #1 said everyone was nice to her and that she was doing good and had no concerns. Resident #1 appeared pleasant, free from apparent injury, and in no distress. During an interview on 10/12/2023 at 2:40 p.m., CNA B said she was not at the facility during the incident with Resident #1 and Resident #2 but that she normally takes care of Resident #2. CNA B said that if she witnessed a male resident with his hand in a female residents brief she would immediately get the charge nurses. CNA B said Resident #2 had no inappropriate behavior under her care and would have never thought he would have sexually abused a resident. CNA B said Resident #1 is crying and emotional at baseline and that they do not normally interact. CNA B said she did not talk with either resident about what happened and that residents have been getting along. CNA B said to prevent abuse the facility has provided in-services on abuse. During an interview on 10/12/2023 at 3:01 p.m., CNA C said she had been employed at the facility for 10 years and did not take care of Resident #1 or Resident #2. CNA A said she arrived to the facility during reporting of the incident and was aware that Resident #2 was reported to have been fondling Resident #1. CNA C said she felt that residents are safe and that there were no other residents involved with Resident #2 because she knew a majority of the residents for a long time when they were at the old facility building. During an interview on 10/12/2023 at 3:11 p.m., LVN C said she had been employed at the facility for 13 years and normally cares for Resident #1 and Resident #2. LVN C said Resident #1 was pleasant today and sometimes cries for unknown reasons at baseline. LVN C said Resident #2 had never had any history of inappropriate behavior. LVN C said she was not working when the event occurred, but that Resident #2 was sent to the behavioral hospital and will not be coming back. LVN C said there was an additional fight since incident between two residents and that it was behavior on aggressors' part, and he was also sent to a behavioral hospital. LVN C said she felt that residents are safe with those two residents out of the facility. LVN C said Resident #4 went into Resident #3's room and accused him of laying in his bed, but he was not in his right room. LVN C said she was taking care of Resident #3 and that he was doing good and had no changes in his mood or behavior. Review of a facesheet with no date and admission MDS , dated 08/24/2023, for Resident #3 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: dementia with other behavioral disturbance, major depressive disorder, cognitive communication deficit, muscle weakness, and intermittent explosive disorder. Review of MDS, dated [DATE], for Resident #3 revealed he had a BIMS score of 13, indicating he was cognitively intact and functional status revealed he was non-ambulatory. Review of care plan dated 10/12/2023, for Resident #3 revealed the resident has limited physical mobility related to dementia with a goal to remain free from complications of skin breakdown to include interventions of wheelchair use for locomotion. 455673 Page 16 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of a facesheet with no date and admission MDS, dated [DATE], for Resident #4 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses including: Parkinson's disease, psychotic disorder with delusions and hallucinations due to known physiological condition, schizoaffective disorder, bipolar type, dementia, insomnia, and recurrent depressive disorders. Review of MD notes, dated 09/28/2023, for Resident #4 revealed his psychiatric affect and mood were appropriate and that he was cooperative with care. MD notes revealed his current plan of care and medications were continued as ordered and to notify of any changes. Review of MDS for Resident #4, dated 10/12/2023, revealed Resident #4 had a BIMS score of 05, indicating severe cognitive impairment. Review of care plan for Resident #4, dated 10/11/2023, revealed he had a focus including Parkinson's disease and psychotropic medication use with goals for him to remain free of further signs and symptoms, discomfort, or complications related to Parkinson's disease and psychotropic drug use through review date. Care plan interventions for Resident #4 included to monitor/document /report any signs and symptoms of medication side effects such as dizziness, somnolence, insomnia, confusion, and any targeted behavior such as violence/aggression towards staff and others. Review of progress notes dated 10/11/2023, for Resident #3 revealed resident had a physical altercation with another male resident who entered his room while he was laying in the bed. Progress notes revealed that Resident #3 reported, he came into my room, and I asked him to get out, but he wouldn't leave. He told me that l was in his room in his bed! I told him no I was in my bed, and he needed to leave. He came and started to hit me, and I hit him back. Progress notes revealed Resident #3 had a laceration to his nose and a bruise to his left ear and received an order for x-ray of facial bones. Progress notes revealed staff attempted to notify RP B and a message was left by staff on his voicemail. Progress notes revealed resident was resting in bed without distress post incident, first aid provided, and that staff would continue to observe. Progress notes revealed Resident #3 refused transfer to emergency room for evaluation and treatment and left ear was swollen and reddish/purple in color. Review of Skin Observation Worksheet signed by the DON, dated 10/11/2023, revealed Resident #3 had a bloody nose, skin split to bridge of nose, red edema, and a possible scratch behind his left ear. Review of x-ray of facial bones report, dated 10/12/2023, revealed Resident #3 had no significant findings. Review of progress notes, dated 10/11/2023, revealed Resident #4 was involved in a physical altercation with another male resident. Progress notes revealed Resident #4 was noticed at 200 hall exit door and then entered another resident's room at the end of that small hallway. The resident room he entered then activated the call light for assistance with getting him out of his room and told Resident #4 several times to get out of his room. Progress Notes revealed Resident #4 then became angry telling Resident #4 to get out of my bed. Progress notes revealed Resident #4 then hit Resident #3 in his nose and ear causing his nose to bleed. Progress notes revealed Resident #4 continued to swing at nursing staff when removing him from room. Progress notes revealed Resident #4 continues to have increased anxiety, uncooperative with redirection, and residents family member was informed. Progress notes revealed staff approached Resident #4 to interview him on alleged incident and he was noted to be sitting up in wheelchair in doorway of room, agitated, verbally aggressive, and had attempted 455673 Page 17 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety to swing his fists at staff members in the hallway who were standing outside doorway of resident room. Progress notes revealed staff approached him in calm, friendly voice and asked what was going on and resident stated nothing. Progress notes revealed that when asked if he hit another resident, Resident #4 stated, Yes, I went down there. I started hitting him. Progress Notes revealed he then began to mumble and was incomprehensible. Progress notes revealed Resident #4 had unclear and unintelligible speech at times and MD was notified new order was received to transfer resident to behavioral hospital. Residents Affected - Few Review of witness statement by CNA D, dated 10/11/2023, revealed she went to answer the call light for Resident #3's room and found Resident #4 in the room with Resident #3. Witness statement revealed residents were fighting and CNA D tried to break it up when Resident #4 turned and began trying to fight her. Witness statement revealed CNA D then told her coworker to get the nurse. Review of witness statement by CMA B, with no date, revealed the following: We were at the nurse's station. A staff ran up and said two men residents are fighting. One of the residents got CNA D blocked in the room. Two nurses and I ran down the hall to the last room. We walked in the room. It was (Resident #3)'s room and his nose was red and bleeding. Nurse asked him what happened because he was laying in the bed bleeding. He said he hit me in the nose. (Resident #4) had hit him. Staff removed (Resident #4). He was still trying to fight. Another nurse helped and took care of (Resident #3)'s nose. Review of witness statement by LVN D, dated 10/11/2023, revealed the following: This nurse was at the nurse's station when CNA's called for me to come down the hall because two residents were having an altercation. Upon arrival to (Resident #3's) room this nurse observed (CNA D) trying to remove (Resident #4) from the room. (Resident #4) was being combative and very upset. (Resident #3) is noted to be bleeding from his nose and all down his face. A laceration is noted to the left side of (Resident #3's) nose and a bruise to his left ear. (Resident #3) reports that he asked (Resident #4) to get out of his room and (Resident #4) hit him telling him this was his room and he needed to get out of his bed. (Resident #3) reports that he hit him back defending himself. (Resident #4) is up the hallway with other staff at this time. (Resident #3) denies any pain. No distress noted. Review of employee statement by LVN B, dated 10/11/2023, revealed the following: This nurse was walking up toward 100 hall when I saw staff members rushing towards (Resident #3's room). I brought coffee to a resident and then started down 200 hall. I saw the resident (Resident #4) being wheeled out of the (Resident #3) room by a staff member. He was swinging trying to hit her. The resident had hit another resident (Resident #3's room number) in the face and ear causing that resident's nose to bleed. This nurse cleaned the blood off the resident (Resident #3). (Resident #4) also tried to hit various other staff members. Review of provider investigation report with no date revealed Resident #3 and Resident #4 had an altercation on 10/11/2023 at 1:10 p.m. witnessed by CNA D. The brief narrative summary of report revealed Resident #4 entered Resident #4's room and an argument ensued resulting in physical aggression with each other. Assessment details of report revealed Resident #4 struck Resident #4 in the nose leading to epistaxis (nosebleed), bruising, and edema to left ear and Resident #4 had superficial scratch to this face left of nose with no other injuries noted. Assessment details revealed Resident #4 455673 Page 18 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was referred for a psychiatric evaluation at behavioral hospital and Resident #4 assessments to be completed every shift to monitor for emotional distress. Actions and Notifications section revealed MD, both RP's, administrator, and DON were notified, and staff in-services were conducted on resident-to-resident violence and de-escalation of situation, reporting, and abuse and neglect. Provider investigation report revealed one on one supervision with Resident #4 was completed on 10/11/2023 and 10/12/2023. Review of Provider Investigation Report by DON, with no date, revealed resident-to-resident altercation incident between Resident #3 and Resident #4 occurred on 10/11/2023 at 1:10 p.m. Provider Investigation Report revealed in-services were provided to staff on resident-on-resident violence and de-escalation of situation, reporting, abuse and neglect. Review of progress notes for Resident #4, dated 10/12/2023, revealed he continued to be combative with staff during transport to behavioral hospital and driver had to pull over and contact EMS. During an interview on 10/12/2023 at 4:07 p.m., LVN A said she was taking a resident back to her room on 10/08/2023 and heard the aide yell for her. LVN A said they started walking down the hall to the aide and Resident #2 was seen with his hand in Resident #1's brief and was then seen in his room washing his hands. LVN A said Resident #1 was crying and upset but she was not able to say what happened. LVN A said she notified ADON immediately and the administrator and protected Resident #1 until they arrived. LVN A said when she asked Resident #2 at first, he denied the incident then later when asked he said, Yeah, I did it. LVN A said she asked Resident #2 if he did it before and he said no it was the first time. LVN A said Resident #2 kept trying to avoid that question. LVN A said she assessed Resident #1, obtained her vital signs, took a picture of the brief before they took it off and looked at the skin in that brief area and she had a very little fingernail width scratch to the right side and if you dab it with a wet cloth it had a drop of blood on it so it was fresh and from what LVN A saw it did appear he assaulted her due to her scratch in area and because she blurted out don't put it in there which was not normal for her to say. LVN A said CNA A told her she saw Resident #2 with his hand in Resident #1's brief and CMA A was the aide that came to the 200 hall calling her name. LVN A said Resident #2 had no history of inappropriate behavior since she has been employed in April 2023 and that their rooms were directly across from each other. LVN A said the resident had a roommate but that it appeared Resident #2 shut that curtain in her room because the curtain was pulled all the way to the end of the bed. LVN A said the incident happened on Sunday, 10/8/23, and that she had taken care of Resident #1 following the incident and appeared at baseline in no distress. LVN A said the facility put interventions in place to protect the resident and prevent sexual abuse from occurring by placing Resident #2 on one-on-one monitoring until he was discharged , frequent 30 minute checks on Resident #1, police were notified and investigated on-site, and staff had received a couple of in-services on different kinds of abuse and neglect following the incident. LVN A said she had no concerns with any other residents showing signs of sexual abuse. During an interview on 10/13/2023 at 9:27 a.m., CNA A said the administrator was the abuse coordinator. CNA A said she was coming out of hall on 10/08/2023 around 3:45 p.m. to do her rounds and Resident #2 was in Resident #1's room with his hand in her brief and she told him to stop and yelled for two aides to assist. CNA A said Resident #1 was crying and Resident #2 backed his wheelchair in the other room and started washing his hands. CNA A said Resident #2 did not say what he was doing and that she suspected sexual abuse. CNA said the nurse called and notified someone to let them know it happened and did a skin assessment. CNA A said the brief was open and appeared it had been messed with. CNA A said Resident #1 was doing fine now at baseline and does not remember what happened. CNA A said the nurse called the responsible party and let him know what happened and the police came the 455673 Page 19 of 20 455673 10/20/2023 Parkwood IN the Pines 902 Hill Street Lufkin, TX 75904

F 0607 Level of Harm - Immediate jeopardy to resident health or safety same day. Resident #2 had no behavior prior to this and had no behavior and did not know if this had happened before. CNA A said interventions were put in place to protect residents from further abuse by placing Resident #2 on one-to-one monitoring, moving Resident #2 to a behavioral hospital, and in-services were conducted on sexual abuse. C[TRUNCATED] Residents Affected - Few 455673 Page 20 of 20