Health inspection·November 26, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 4 of 5 residents (Residents #1, #2, #3, and #4) reviewed for abuse, neglect, and exploitation. 1. The facility failed to protect Resident #2 from physical abuse when Resident #1 hit Resident #2 on the arm and kicked him in the leg on 10/15/2025. 2. The facility failed to protect Resident #1 from physical abuse when Resident #2 hit Resident #1 in the face for hitting him on the arm on 10/15/2025. 3. The facility failed to protect R #4 on 11/24/25 from being hit by R #3 in the hall of the women's locked unit. These failures could place residents at risk for physical or psychological harm or injury.Findings included: 1. Record review of Resident #1's face sheet, dated 11/26/2025, revealed a [AGE] year-old male with an admission date of 06/14/2025. Resident #1's diagnoses included Myocardial Infarction (commonly known as a heart attack, occurred when blood flow to a part of the heart muscle was blocked and lead to tissue damage), Congestive heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup and other various symptoms), Chronic Kidney Disease (also called chronic kidney failure, involved a gradual loss of kidney function), Non-Traumatic Subacute Subdural Hemorrhage (a serious condition characterized by bleeding in the brain without any external injury, often requiring prompt medical attention), Dementia (a group of symptoms affecting memory, thinking and social abilities), Cognitive Communication Deficit (communication difficulties which arose from cognitive impairments), and Schizoaffective Disorder (a mental health condition which was marked by a mix of symptoms such as hallucinations, delusions, depression, mania, and a milder form of mania called hypomania). Record review of Resident #1's Quarterly MDS assessment, dated 09/16/2025, revealed a BIMS score of 03, which indicated severely impaired cognition. Resident #1's MDS also revealed Resident #1 experienced disorganized thinking, as well as felt down, depressed or hopeless. Resident #1 also exhibited physical and verbal behaviors toward others and self. Record review of Resident #1's care plan, initiated 08/20/2025, revealed Resident #1 had an episode of physical aggression toward staff, in which he raised his hand in a motion to hit a staff member, but had not followed through. Interventions included administer medications as ordered, analyze triggers and what de-escalated the behavior, assess and address for contributing sensory deficits, and provide physical and verbal cues to alleviate anxiety. Resident #1's care plan, initiated 08/01/2025, revealed Resident #1 was observed yelling and swinging on staff members, and interventions included monitor and document any signs or symptoms of Resident #1 posing danger to self or others, and a psychiatric consult. Record review of Resident #1's nurse's note, written by the ADON, dated 10/15/2025, revealed Resident #1 was involved in an episode of physical aggression from another resident in which he reacted and hit the other resident in return. Resident #1's social service's note, dated 10/15/2025, follow-up with Resident #1 after the incident revealed he did not remember the incident. Record review of the facility's incident Page 1 of 7 455923 455923 11/26/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reports revealed Resident #1 had a Physical Aggression Received Incident on 10/15/2025. 2. Record review of Resident #2's face sheet, dated 11/26/2025, revealed an [AGE] year-old male with an original admission date of 09/02/2025, and a current admission date of 10/28/2025. Resident #2's diagnoses included Peripheral Vascular Disease (a slow and progressive disorder of the blood vessels, such as narrowing, blockage, or spasms in a blood vessel), Type 2 Diabetes (a chronic condition which affected how your body metabolized sugar (glucose), leading to high blood sugar levels and various health complications), Vascular Dementia (describes significant symptoms which affected daily living and may be similar to mild cognitive impairment but were more severe), and Anxiety (intense, excessive and persistent worry and fear about everyday situations) Record review of Resident #2's Significant Change MDS assessment, dated 10/08/2025, revealed a BIMS score of 03, which indicated severely impaired cognition. Resident #2's MDS also revealed he exhibited physical behaviors toward others. Record review of Resident #2's care plan, initiated 09/19/2025, revealed Resident #2 was physically aggressive at times. Interventions included analyze triggers and what de-escalated the behavior, provide physical and verbal cues to alleviate anxiety. Resident #2's care plan, initiated 09/19/2025, revealed Resident #2 had acute confusional episodes with inattention and disorganized thinking. Interventions included encourage friends, family and caregivers to be at bedside during acute episodes in order to provide familiarity and support, and redirect and provide gentle reality orientation as required. Record review of Resident #2's nurse's note (written by LVN-A), dated 10/15/2025, revealed Resident #2 was in the dining room and threw his cup of water, and he started pushing tables and chairs. Resident #2 swung his arm and hit Resident #1 who was trying to assist him, so Resident #1 punched him in the face, and Resident #2 then proceeded to kick Resident #1. Record review of the facility's incident reports revealed Resident #2 had a Behavior Incident on 10/15/2025. Record review of the Provider Investigation Report dated 10/15/2025 revealed at approximately 8:20 AM the DON received a report that Resident #2 was grabbing and swinging his arms in the dining room in the Memory Care Hall 2 when he struck Resident #1 with minimal force. Resident #2 had been placed on the floor for safety concerns. Resident #1 was struck by Resident #2 with minimal force to the left cheek. Residents were immediately separated. Head to toe assessments were completed on both residents, with no findings of bruising or discoloration of skin. Resident #2 was placed one to one until cleared by psychiatric services. In-services were completed on abuse and neglect, de-escalation, and removing residents that are non-agitated from the dining room. Ombudsman, Responsible Parties, Team Health, Psychiatric Services, and Medical Director were notified of the incident, as well as the local PD. Neither resident had the intention of harming each other, nor did they remember the incident. Both residents had a BIMS score of 3, impaired cognition. Labs were ordered with no abnormalities. Record review of the Provider Investigation Report dated 10/15/2025, statement from CNA-B, revealed Resident #2 was agitated and swinging his arms around in the air, and he accidentally struck Resident #1 who was within arm's reach. Resident #1 had been asked to stand aside, but he did not move immediately and was struck on the right arm. Resident #1 reacted to being struck by swinging back and making contact with Resident #2's left side of face. Residents were immediately separated and staff stayed one-to-one with Resident #2. 3. Record review of Resident #3's face sheet revealed an [AGE] year-old female initially admitted on [DATE] and then readmitted on [DATE] with diagnoses of Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Dementia (A group of thinking an social symptoms that interferes with daily functioning), Psychotic Disorder with Delusions a type of psychotic disorder 455923 Page 2 of 7 455923 11/26/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some characterized by the persistent presence of delusions, or fixed false beliefs, for at least one month with other major symptoms like hallucinations or disorganized thinking), Major Depressive Disorder (A common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in previously enjoyable activities), and Altered Mental Status (a change in a person's Level of consciousness, alertness, and cognitive function). Record review of R #3's Care Plan date 10/20/25 revealed R #3 has impaired cognitive function related to alzheimer's dementia with a BIMs of 3. R #3 has a behavior problem related to dementia, had delusions with paranoia, and adjustment problems to nursing home setting. R #3 has acute confusional episodes and has disorganized thinking. R #3 is delusional at times and has vocalized that staff are out to kill her. R #3's behaviors are to be monitored, recorded, and reported if new onset signs and symptoms of delirium: changes in behaviors, altered mental status, wide variation in cognitive function throughout day, communication decline, disorientation, lethargy, restlessness and agitation. Altered sleep cycle, dehydration, infection, delusions, hallucinations. R #3 has refused showers, didn't change her clothes often, and took out her dentures and hid them. R #3 is to resist help with activities of daily living reassure the resident, leave and return 5-10 minutes later, and try again. R #3 uses psychotropic medications related to Alzheimer's disease. R #3 uses antipsychotic medications related to psychotic disorder with delusions due to known physiological condition monitor interaction or resident with others for appropriateness. Record review of Resident 3 #'s MDS Quarterly dated11/06/25 revealed a BIMS score of 4 which indicates severe cognitive impairment which suggests the individual has a significant difficulty with cognitive tasks like memory and orientation and may need substantial help with daily activites. R #3's cognitive patterns revealed behaviors of inattention and disorganized thinking were present. R #3's mood interview revealed feelings of depression, hopelessness and sometimes social isolation . R #3' behavior symptoms revealed verbal behavior symptoms of threatening others, screaming at others and cursing at others present one to three days. R #3 other behavioral symptoms not directed to others for example hitting or scratching self, pacing, and verbal /vocal symtoms like screaming/ disruptive sounds. R #3's functional abilities revealed she needed assistance and supervision for activities of daily living. Record review of R #3 's progress notes dated 11/25/2025 revealed staff met to review and discuss physical and verbal aggression that was initiated by resident on 11/24/25. Interventions as follows: X-rays, close supervision, and psych to review medications. In observation R #3 sat up on the side of the bed watching tv. R #3 is in a calm and pleasant mood, no behaviors noted, voiced not complaints and no signs or symptoms of distress or discomfort. 4. Record review of Resident #4 face sheet revealed an [AGE] year-old female initially admitted on [DATE], and readmitted on [DATE] with diagnoses of Dementia (A group of thinking an social symptoms that interferes with daily functioning), Depression (a group of conditions associated with the elevation or lowering of a person's mood), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and unspecified psychosis (a diagnostic category for a patient experiencing psychotic symptoms like delusions or hallucinations, but where there is not enough information to make a specific diagnosis, or the symptoms don't meet the criteria for another disorder). Record review of Resident 4 #'s Care Plan date initiated on 11/20/25 R #4 was bumped in the mouthby another resident on 11/24/25. R#4 sustained a superficial abrasion to lower lip noted and complained of right elbow pain. R#4 received wound care until resolved and was monitored for signs and symptoms of infection. R #4 was given an x-ray to right elbow due to complaint of pain. R#4 has behaviors related to Dementia administer medications as ordered. Monitor and document for side effects and effectiveness of medications. R #4 has impaired 455923 Page 3 of 7 455923 11/26/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognition related to cerebrovascular accident and Dementia with a BIMs of 9. R #4 is easily angered with staff and other residents. R#4 uses psychotropic medications related to Dementia and mood stabilizer. R#4 is to be monitored, documented, reported as needed for any adverse reactions of psychotropic medications like unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. R#4 has expressed having little interest or pleasure in things and feeling tired all of the time. Record review of Resident #4's MDS Quarterly dated 11/06/25 revealed a BIMS score of 9. R #4's mood assessment indicated the resident felt social isolated sometimes. R #4 had a functional limited range of motion to the lower extremity and uses a cane or crutch. R #4 functional abilities assessment revealed the resident needs supervision or touching assistance with moderate assistance with showering and dressing. Record review of Resident #4's progress notes dated 10/27/2025 to 11/26/25 documented on 11/24/2025 at 3:12 P.M. Placed phone call to responsible party to inform him that resident was approach by another resident who was telling all the ladies that they were gay and this resident got up and approached the other resident and they ended up on the floor pushing each other with their arms and no injuries were noted for this resident and responsible party thanked the undersigned for calling and stating they will be picking up his mom for Thanksgiving day. On 11/24/25 at 4:57 P.M. R #4 told a staff member that her right elbow is hurting so physician was notified, and he gave and order for a right elbow x-ray. R #4's progress notes documented on 11/24/25 5:06 P.M. Social Services (SS) visited with R#4 and asked resident if she remembered the incident that happen today R #4 stated that she could not remember anything. SS also tried to complete a [NAME] Assessment but was unable due to cognition. SS offered support as needed. On 11/25/25 at 8:12 A.M. SS visited R #4 and SS asked how she was doing today, and she stated that she was having a blessed day and enjoying her breakfast. Resident thanked SS for visit. SS offered support as needed. In observation and interview on 11/26/25 at 11:03 AM Resident #3 was observed lying in bed watching television was alert and well dressed in clean clothes. R#4 had a nurse in the room because she was placed on a 1 to 1 for monitoring. The state surveyor asked R #4 about the incident with R#4 and she stated she did not remember have any type of altercation with anyone. R #3 seemed confused and asked when her daughters were coming to visit her. In observation and interview on11/26/25 at 1:36 PM R#4 was observed in her room lying in bed staring out her window she was alert and able to speak. R #$ stated R#3 was arguing and yelling with her and stated the she and other residents were lesbians. R #4 stated after that she does not remember what happened just remembers being on the floor and her necklace was busted and that upset her. R #4 stated she was not afraid of R #3 but did not want contact with her. R #4 stated she did not have any concerns with anyone else and was happy at the facility. In an interview on 11/26/2025 at 10:02 AM, CNA-B stated although Resident #2 started it, in the end, Resident #1 and Resident #2 both ended up hitting each other. Resident #2 liked to get out of his chair and crawl in the floor, and he tried to pull himself up on someone else's chair and kept grabbing the arms of the chair to pull himself up. Resident #1 attempted to help Resident #2 get up, and maybe Resident #1 thought Resident #2 tried to hurt him, so he swung and hit Resident #2 in the arm; then Resident #1 reacted by swinging back and hit Resident #2 in the face. CNA-B stated the residents were separated, and staff were in-serviced over abuse and neglect. In an interview on 11/26/2025 at 11:15 AM, the ADON stated she was not here when the incident between Resident #1 and Resident #2 occurred, but she was notified Resident #2 was on the ground and Resident #1 tried to assist him up, and Resident #2 hit and or kicked Resident #1, so Resident 455923 Page 4 of 7 455923 11/26/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #1 swung back and hit Resident #2 in the face. The ADON stated Resident #2 was not combative when he was first admitted to the facility, but when his Seroquel was discontinued, he became combative. The ADON stated they could not figure out the reason Resident #2 was on Seroquel, and they could not find a good reason to keep him on the Seroquel, which was why it was discontinued. The ADON stated Resident #2 was not always able to be redirected, so he was given prn medication for his anxiety and aggressive behaviors, but staff always assessed for things prior to prn medications, such as hunger, thirst, pain, and/or anxiety to see if anything caused Resident #2 to have these outbursts or behaviors. After medication reviews were completed by both the primary provider and the Psych provider, as well as care plan meetings with the RP, it became clear the Seroquel had been used to help control these behaviors, which was why the behaviors became more prevalent after discontinuing the Seroquel. In an interview on 11/26/2025 at 12:23 PM, the DON stated she was notified Resident #2 was on the ground and Resident #1 tried to assist him up, and Resident #2 hit and or kicked Resident #1, so Resident #1 swung back and hit Resident #2 in the face. Resident #2's Seroquel was discontinued after admission and Ativan was ordered for his anxiety and aggressive behaviors. Resident #2 could wheel himself in his wheelchair, but he preferred to get out of his chair and crawl around on the floor, which was care planned. He sometimes struggled to get back up into his chair after being on the floor, which was what happened when this incident occurred. Staff had tried to redirect Resident #1 from the area of Resident #2, but as staff were attending to Resident #2, Resident #1 came back over and tried to assist Resident #2 up, which was when the resident to resident incident occurred. Resident #2's Seroquel was reordered and seemed to have helped, but when Resident #2 has had a bad day, or acted out, staff would implement an informal 1:1 to have someone sit with him or have family visit him or talk to him to help calm him down. Attempted interview on 11/26/2025 at 1:21 PM with Resident #2, but he could not recall the event. Attempted interview on 11/26/2025 at 1:27 PM with Resident #1, but he could not recall the event. In an interview on 11/26/25 at 4:10 PM, LVN-A stated she was here when the incident between Resident #1 and Resident #2 occurred. She stated Resident #2 tried to get back in his wheelchair, and Resident #1 tried to assist him, but Resident #2 hit Resident #1 on the arm, so Resident #1 responded by hitting Resident #2 in the face. LVN-A stated she had not seen Resident #2 initially hit Resident #1, but it was reported to her by the CNA. LVN-A stated, although there was no history of these two residents being aggressive with each other in the past staff try to keep the residents separated or out of reach from each other, and when the incident occurred, staff were trying to redirect the residents away from each other, but the residents kept getting closer to each other every time staff were occupied assisting with the situation. LVN-A stated that when there is a resident-to-resident altercation, residents are immediately separated from each other. It is reported to the Administrator and DON, and head to toe assessments are completed. In an interview on 11/26/25 at 10:45 AM with LVN F stated she did not witness the incident but knew R #3 and R #4 well and stated R #3 was was very aggressive at times and tends to act this way as the day is ending sun downs every day. LVN F stated R #4 is calm and keeps to herself like to participate in activities and gets along with other residents. Lvn F state R #3 was immediately moved out of the locked unit and placed on a 1 to 1 to monitor in the room she was relocated. LVN F stated R #4 was upset about her necklace and the facility replaced it with another one and she was happy. LVN F stated an in-service was given to all staff members that same day. LVN F stated was able to identify the different types of abuse and knew the abuse coordinator was the administrator.In an interview on 11/26/25 at 11:04 AM with CNA E stated she was covering for CNA and as she was helping another resident when she heard CNA C call for help. CNA C stated as she arrived the residents were already separated and were 455923 Page 5 of 7 455923 11/26/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some being picked up off the floor. The ADON also ran into help with the altercation and separated the residents and began the assessment and R #3 has an abrasion 3mm x 1mm to the left elbow but she did not complain of pain. CNA E stated an in-service was administered to staff after the incident occurred and was able to identify the administrator as the abuse coordinator and the different types of abuse. In an interview on 11/26/25 at 02:01 PM CNA C stated she was in a room with another CAN and heard R#3 yelling and she quickly ran towards the commotion. CNA C stated as she arrived she yelled for help and stated R #4 was yelling out R#4 was a lesbian with another resident and saying other vulgar sexual acts. CNA C stated as R #3 was yelling she grabbed R#4 by the lips and mouth pushed her down and R #4 was trying to get away from R #3. She quickly tried to separate them as help arrived both R #4 was picked up off the floor and R #3 was taken away and R#4 was assessed for injuries. CNA C stated the last in-service on abuse was the same day as the incident two days ago, the abuse coordinator was the administrator and could identify the different types of abuse. In an interview on 11/26/25 at 2:14 P.M. with CNA D she stated she was walking down the hall and with the other CNA D and saw two residents on the floor both were hitting each other. CNA D stated she and the other CNA quickly began to help separate the two residents. CNA D stated as she helped separate the two residents she saw a red marking on the elbow R#3. CNA D stated R #3 was immediately removed from the unit and moved to hall #5 with 1 to 1 monitoring. In an interview on 11/26/25 at 2:30P.M. Social Services (SS) worker stated has had follow up visits with both residents. The SS stated both residents had not shown any signs of fear staff or other residents. R #3 has had aggressive behaviors in the past and is very occupied about residents being lesbians and has a daughter who is a lesbian and maybe upset about that issue in her family. The SS stated she tried to redirect when R#3 when she had those episodes. R #4 did not remember too much about the altercation but was in good spirits. R #3 was placed on a 1 to 1 and moved out of the unit and no care plan meetings have been held for either resident yet. The SS stated if any residents showed any signs of aggressive behaviors the staff would try to keep the residents apart and deescalate any situation which occurred between residents. The SS stated the staff meets every day to decide which preventive measures need to be implemented or changed to prevent abuse in the facility. The SS stated there are in-service and training classes for all procedures and protocols that ensured facility was in compliance. The SS stated the last in-service was 2 days ago, could verbalize the types of abuse maned the administrator as the abuse coordinator. In an interview on 11/26/25 at 3:03 pm with the DON she stated after she spoke with the staff R #3 was having an issue with family a member being lesbian and was accusing other female residents of being lesbian. The DON stated R #3 has been evaluated by a psych hospital in the past for aggression. The DON stated R #3 was heard yelling about female residents in the locked unit being lesbians and one R #4 got up to ask her to stop yelling and R #3 grabs R#4 by the lip and fell and brought R#4 with her. The DON stated the residents were separated and assessed, and R #3 was removed from unit and placed on a 1 to 1 monitoring. R #4 complained about elbow pain but refused medication and was more upset about a necklace that was busted during the altercation. The DON stated later that day neither resident could remember the incident. The DON stated R #3 was in the process of setting up medication evaluation with the facility physician and kept being monitored to prevent any other incidents from occurring. The DON stated R #3 tended to be verbally aggressive with family and staff so monitoring was the best way to keep her from hurting other residents. The DON stated the administrator and DON were responsible for ensuring that all policy and procedures were being implemented correctly to keep the facility in compliance. The DON stated the staff development nurse was in charge of training and made sure all the training was being administered in a timely manner. The DON stated the abuse 455923 Page 6 of 7 455923 11/26/2025 Avir at Beeville 600 S Hillside Dr Beeville, TX 78102

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some coordinator was the administrator and she was able to verbalized different types of abuse. In an interview 3:32 P.M. with the ADON stated she received a call on walkie talkie and R3# was talking about the residents being lesbian and having oral sex. The ADON stated the R #3 and R #4 were separated and R #3 was moved to out of unit placed on 1 to 1. The ADON stated responsible partys for the residents were notified. The ADON stated was R #3 was given medication by the physician to address the aggression R #3 was experiencing. Notified the psych doctor of the incident so the resident continued to be monitored for aggressive behaviors. The ADON stated she was not aware of any policy and procedure for monitoring or how it was implementation in of the prevention of resident-to-resident abuse. The ADON stated no care plan meetings were done for either resident. The ADON stated the care plan coordinator is responsible for ensure all trainings are done in time. The ADON stated normal day to day nursing would monitor the residents for new behaviors. The ADON d verbalized the types of abuse and administrator is the abuse coordinator. The last training was 2 days ago for abuse and neglect for this incident. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation policy, revised April 2021, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: B. Other Residents, J. Any other individual. 455923 Page 7 of 7