Health inspection·August 20, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 each resident had the right to be free from abuse for two residents (Resident #1; Resident #2) of 6 residents reviewed for abuse/neglect.The facility failed to prevent resident to resident abuse on 06/20/25 when resident #2 pushed Resident #1 which caused resident #1 to stumble backwards. After being pushed by Resident#2 grabbed a plastic vase and hit Resident #2 on the vase. This failure placed residents at risk for serious injury. Record review of Resident#1 face sheet revealed an [AGE] year-old male initially admitted on [DATE], with diagnoses of Unspecified mood(active) disorder, Dementia (A group of thinking an social symptoms that interferes with daily functioning), , major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Non- Alzheimer's Dementia (A group of dementias that are not caused by Alzheimer's disease, the most common form of dementia. Record review of Resident #1's MDS Quarterly dated 07/31/2025 revealed Resident #1 had a BIMS Score of 04-severe cognitive impairment with behaviors of inattention and disorganized thinking, depressive mood and at times felt isolated. Resident #1 needed partial to moderate help with toileting and dressing ADLs. Resident #1 was able to transfer to toilet and chair with touch assistance. Resident #1 was able to walk up to 50 feet with two turns with moderate assistance. Resident #1 was diagnosed with hypertension and NonAlzheimer's Dementia (A group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #1's Care Plan date 04/21/25 revealed Resident #1 expressed little activity involvement related to activity intolerance date Initiated: 04/21/2025 Revision on: 06/23/2025 Resident #1. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Resident #1 has Impaired cognitive function/ dementia or impaired thought processes related to Dementia. Care includes redirection and supervion as needed. Initiated 06/20/25 and Revised on 06/24/25. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Resident #1 has impaired cognitive function/dementia or impaired thought processes related to dementia. Date Initiated: 07/31/2025 Revision on: 08/19/2025. Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.) and document per facility protocol. Date Initiated: 04/21/2025 Revision on 04/22/2025.Record review of Resident #1's progress notes dated 06/20/25 written by the Social Worker revealed Resident #1 was seen being confrontational with another resident. Social Worker stepped in and attempted to redirect and Page 1 of 10 675312 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stop the two, as other staff came to aid as well. In the mist of the confrontation Social Worker witnessed Resident #1 with the small container in his hand making contact with the Resident #1. Residents separated quickly. Review of Resident's #1's progress note dated 06/20/25 written by LVN A revealed This nurse heard some commotion coming from dining room area and then social worker started yelling for someone to come and help. Upon entering dining room, I saw both residents being separated from one another. After head-to-toe assessment [Resident #1] had no apparent injuries at this time. [Resident #2} also denied any pain RP, and MD called and notified of the altercation. Resident assed for pain, new skin injuries (none noted), vitals taken, RP and MD called and made aware of situation. Progress note dated 06/20/2025 written by DON revealed DON called into dining room due to resident-to-resident altercation. Other employees had already separated both residents. Resident #1 appeared upset and head- to- toe was immediately completed, no skin issued noted. MD and RP was notified by charge nurse LVN A. Review of Resident #1's progress notes dated 06/21/25 written by RN B revealed Resident #1 was observed in dining room this morning and continues to show aggression to another resident by voicing for other resident to not get near him. The resident was easily redirected at this time. Staff aware of situation, usually starts at mealtimes when both residents are in dining room. Care is ongoing and was safety maintained the RP was made aware. Progress note dated 06/21/25 revealed CNA reported she had to remove other residents from Resident #1 table due to he was getting upset and becoming angered. Residents separated and no other issues noted.Record review of Resident #1's incident report conducted by the Administrator/Abuse Coordinator dated 06/20/2025 revealed At approximately 4:30 PM on June 20, 2025, social worker was walking down the hallway when she heard a commotion coming from the dining hall. Upon entering, she observed [Resident #1] standing over [Resident #2]. [Resident #2] then pushed [Resident #1] causing him to stumble backward [Resident#1] quickly regained his balance, reached for a small plastic vase on the table, and struck Resident #2 on the head. At that time, nursing staff and facility management arrived on the scene and successfully intervened, separating the two residents. RP notified NP notified, MD notified. A head-to toe assessment and psychosocial assessment were completed for both residents. [Resident #1]and [Resident #2] were placed on 15-minute checks to ensure safety. [Resident #1] was referred to psych services for further evaluation, and [Resident #2] continues under his existing psych services. MD cleared both residents to come off 15-minute checks and return to the regular facility monitoring on 06/26/25. Record review of Resident #2's Face sheet revealed a [AGE] year-old male initially admitted on [DATE] with diagnosis of Mood Disorder (A mood disorder a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior); peripheral vascular disease( A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); Hypertension( A condition in which the force of the blood against the artery walls is too high); acquired absence of right left below knee; and Non- Alzheimer's Dementia (a group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 09-moderate cognitive impairment and needed some assistance with all ADL's. Resident #2's MDS also revealed disorganized thinking was a behavior continuously present and did not fluctuate. Resident #2's resident mood interview revealed symptoms presence of feeling down, depressed, or hopeless. Resident #2's behavioral symptoms revealed verbal behavioral example given of threatening others, screaming at others, cursing at others, which occurred 1 to 3 days. Resident #2's other behavioral symptoms not directed toward others occurred one to three days. Rejection of care was present 1 to 3 days. Resident #2's MDS revealed he needed moderate to substantial help with toileting, showering, lower body dressing and putting on and taking off footwear. 675312 Page 2 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2's MDS used a manual wheelchair. Record review of Resident #2's Care Plan date initiated 06/18/25 revealed, Resident #2 is at risk for activity intolerance related to major depressive disorder, severe with psychotic symptoms, mood disorder initiated on 12/16/2024 revised on 02/15/2025. Resident #2's care plan revealed has a behavior problem of being accusatory related to major depressive disorder, severe with psychotic symptoms, and mood disorder if reasonable, discuss the resident's behavior. Resident #2 care plan revealed Explanation and reinforcement as to why behavior is inappropriate and/or unacceptable to the resident. Refer to Psych services as needed Initiated on 02/17/2025 Revision on 03/24/2025. Resident #2 care plan revealed he had the potential to be verbally and physical aggressive related to poor impulse control and intervention was to administer medications as ordered and monitor and document for side effects and effectiveness initiate on 12/13/2024 and assess resident's understanding of the situation. Resident #2 care plan revealed to allow time for the resident to express self and feelings towards the situation initiated on12/13/2024 and the interventions were for a psychiatric/psychogeriatric consult as indicated. The DON called into dining room due to a resident-to-resident altercation. Other employees had already separated both residents. Resident #2 was noted with a scratch to left side of head, a scratch and small blood blister to his right hand. Resident #2 refused full head to toe. MD and RP were notified by charge nurse LVN E. And the SW to follow up with psych. Record review of Resident #2's progress notes by the nurse LVN E dated 06/20/2025 revealed the nurse was at the nurse's station and heard someone call for help from the dining room. When the nurse got to the dining room it was noted the resident had an altercation with another resident, employees had already separated the residents, and Resident #2 was being wheeled out of dining room. Resident#2 had not complained of pain or discomfort voiced and tried to do head to toe assessment resident refused. LVN E did note the resident had a small scratch to top of his right-hand, a small blood blister between his index finger and thumb, a small scab like area to left side of forehead. The MD informed. Resident #2 had new orders for UA, CBC, and CMP. The orders were noted, and the resident was also started on every 15 min frequent monitoring to prevent any further incidents. Record review of Resident #2 progress notes dated 06/20/25 revealed the DON was called into the dining room due to a resident-to-resident altercation and other employees had already separated both residents. Resident #2 was noted with a scratch to the point where left side of head, scratch and small blood blister to right hand. Resident #2 refused a full head to toe and the MD and RP were notified by the charge nurse LVN E and the social worker was to follow up with psych. Resident #2 progress notes dated 06/20/25 revealed and the social worker noted Resident #2 was seen being confrontational with another resident and the social worker stepped in and attempted to redirect as other staff came to aid as well and the PCS was notified. Record review of Residents #2 progress notes dated 06/23/25 Resident #2 was being monitored every 15 minutes for an altercation with another resident. Resident # 2 progress notes dated 06/23/2025 revealed team members were keeping the Resident #1 and Resident#2 separated so there was no altercation. In an observation and interview on 08/20/25 at 9:30 AM resident #1 was sitting on his bed watching TV. The state surveyor tried to ask him questions, but he could not hear very well. The state surveyor asked him about the incident with Resident #2 and stated he did not remember any altercation with him and Resident #2. The state surveyor discontinued the interview at that point. In an observation and interview on 08/19/2025 at 10:30AM revealed Resident#1 was observed sitting at the edge of his bed watching TV with the volume up high. The state surveyor asked if she could come in and talk with him, and he did not respond. Resident #1 stated in Spanish he could not hear very well and needed to talk to him very loudly so that he could hear. The surveyor attempted to ask him if he remembered the incident with Resident #2 but only heard some 675312 Page 3 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the question. The surveyor attempted several times to asks questions, but the Resident#2 could not make out what was being asked so the surveyor discontinued the interview. In an observation and interview on 08/19/2025 at 1:42 PM revealed Resident #2 was observed sitting in his wheelchair in front of the nurse's station talking with other residents. Resident # 2 was alert and when he spoke with the other residents was hard to understand and just spoke about random subjects not really follow any type of conversation. The state surveyor asked resident #2 if he could answer some questions, and he stated yes. The state surveyor asked resident #2 if he would like to go to his room and Resident #2 stated he was okay to have the interview where he sat in his wheelchair at the nurse's station. Resident #2 stated he could not remember why or how the incident occurred but did confirm Resident #1 hit him with a truck. Resident #2 stated he did not remember pushing Resident #1. Resident #2 stated there was no argument between them and they had never had any other altercations before. Resident #1 stated he was not afraid of Resident #1 or anyone in the facility. In an interview on 08/19/25 2:26 PM with CNA G stated Resident #1 was always to himself and would get angry with meals if he did not like what was served or did not get what he wanted to eat. CNA G said the resident was often very confused and had to be redirected. CNA G said at one point he did not like anyone sitting with him when he ate. CNA G said the staff had to coax Resident #1in to taking a shower he can get combative at times. CNA G stated the resident had not harmed any staff to her knowledge when he refused to do any of his ADL's. CNA G stated he had a good day if he was getting out of his room and go to the dining room to eat or go to activities. CNA G said a bad day was when the resident stayed in his room most of the day. CNA G stated the last time she had a training on abuse was about month and half ago. CNA G stated when an altercation occurs first thing to do is redirect residents try to get them separated and call for help immediately. CNA G stated a verbal abuse example could be name calling, talking down to a resident, cursing at the resident and tone in their voice in some case. The administrator is the abuse coordinator, and all abuse is to be reported to him immediately.In an interview on 08/19/2025 at 2:49 PM LVN F stated Resident #2 sits in the dining room alone because he likes it. Resident #1is very aggressive with other males and does not like other people around him. CNA G stated she saw Resident #1 began the argument with Resident #2. As Resident #2 left the area serval times to avoid an escalation with Resident #1. CNA G said when Resident #1 sees resident #2 he gets angry, and the staff try to keep Resident #1 and Resident #2 away from each other. CNA G said no other incidents have occurred between Resident #1 and Resident #2. CNA #2 was in the dining room when it occurred over dinner but did not see Resident #2 strike resident #1 with an object and only saw the Resident#! and Resident #2 arguing and the social worker come in and try to separate them. She then began to calm the two residents down. CNA G stated for a while the staff could not have both residents in the dining room at the same time because Resident #1 would get angry. CNA G stated her last abuse training was 2 weeks ago and said the first step to do when an altercation begins is to deescalate the matter by separating the residents and redirect them away from each other and if there is an injury get the nurse an let the abuse coordinator know immediately. In an interview on 08/19/25 at 4:01 PM CNA H stated Resident #1 got agitated he really does not like people around him and especially does not want any one near him in dining room. CNA H stated Resident #1 had never been angry with her while she helped him. Resident #2 was the only one Resident #1 was aggressive with. CNA H walked in the dining room as they were being separated. CNA H said she was Resident #2's nurse for that day and stated Resident #2 was worked up for a while after the incident. CNA H stated Resident #2 had a scratch to his forehead that was scabbed on his head. CNA H stated Resident #2 happened to roll too close to Resident #1 and Resident#1 got angry was what she understood happened in the dining 675312 Page 4 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room and what may have started the incident. Resident #2 had no complaints of pain to head and was acting normal and the nurse did neuro checks on him. In an interview on 08/19825 at 4:33 PM with CNA I, she stated she has been a nurse for both residents at different times. CNA I said Resident #1 keeps to himself likes to eat alone has and she had no issues with him being aggressive in any way. CNA I said Resident #1 l does not like to be helped with ADL's and can be combative with staff. CNA I said Resident #2 yells at times when he gets aggravated but has no problems with any other residents. CNA I said Resident #2 gets combative when staff transfers and bathes him. CNA I said there was no history of aggression with either resident against each other. CNA I said all staff know to keep them apart at all times. CNA I was not present on the day of incident. CNA I stated when she returned two days later, she saw no injuries on either resident. In an interview with 08/19/25 at 4:20 PM the ADON she said she saw the Social Worker and nurses separated Resident #1 and Resident #2 from each other in an altercation that occured in the dining room at dinner time. The ADON said resident #1 had a center piece in his hand and Resident # 2 had a wound that looked like an old scab on his forehead. The ADON stated she was not present during the altercation and arrived after the social worker yelled out for help so she did not see if there was contact made between the residents. The ADON said the staff stayed with Resident #1 and Resident #2 was taken to his room. The ADON said neither resident had altercation with any other residents or staff before this incident occurred. The ADON said the abuse coordinator was immediately notified as well as MD and RP. The treatment Nurse / unit manger did an assessment the next day to give a more thorough head-to-toe. The ADON said as she spoke with Resident #1, he stated Resident #2 had the vase and he took it away from him. The ADON stated she did not consider the incident abuse since both residents had mental issues. The ADON said the last time she had abuse training was 2 weeks ago. The stated staff is trained to deescalate situations that can turn into altercations between residents or staff and residents. The abuse coordinator is to be told immediately of any abuse that occurs in the facility. In an interview on 08/19/25 at 5:20 PM with LVN A she stated she was there during the altercation but understood from conversations in the dining room Resident #1 had walked in the dining room and saw Resident #2 was sitting in Resident #1 spot he likes to sit in and the altercation began. CNA A stated she heard the Social Worker began yelling for help as she quickly made her way to the dining room and tried to help separate the residents. LVN A stated she could not recall what exactly occurred or what happened afterward the dining room clearly but did recall Resident #1 was terribly upset and Resident #2 was taken to his room. CNA A said she assisted with calming Resident #1 and recalled he stated he was going to hit Resident #2. When Resident #1 was asked if he hit Resident #2, he said he did not hit him with plastic vase. In an interview on 08/19/2025 5:45 PM with Social Work was in her office heard scuffle and someone yelled leave me alone! The SW quickly ran into the dining room and when she arrived and saw Resident #1 and Resident #2 had hands on each other. Resident #2 was in his wheelchair and had his breaks on and could not move backward to get away. Resident # 2 was trying to get way from Resident #1as he was standing in front of him and shoved resident #2 away Resident #1 then stumbled back and almost fell. The SW stated Resident #1 had a plastic vase in his hands and tried to take away. SW stated she was calling for help and could not confirm that Resident #1 stuck Resident #2 with the vase. The SW stated as help arrived, she was able to take the vase away from Resident #1. Resident #2 had a old scratch and scab on his forehead. The SW stated she just saw the forehead injuries was not aware of the hand injury. The SW stated no other altercations before this one and after the staff just try to keep him away from each other. The SW stated neither resident has had any other altercations with other residents. The SW said she followed up with the family, resident physician, psychological 675312 Page 5 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evaluations, and how both residents continued with their care. The SW stated Resident #1 continues to be territorial about his dining room spot, so staff try to make sure it is available for him if he eats in the dining room. Record review of the facility's Abuse Protocol dated 04/2019 Indicated: The Patient has the right to be free from Abuse, neglect mistreatment of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the Patient's symptoms. Our facility will not condone Patient Abuse, neglect, mistreatment misappropriation of patient property and exploitation (collectively Patient Abuse by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient consultants volunteers, staff of other agencies serving eh Patient, family members, legal guardians, sponsors, friends or other individuals. Abuse is defined as the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by a individual, including a caretaker, of goods or services that are necessary to attain or maintain physical or mental and psychosocial well-being. Instances of abuse of all Patient/Resident, irrespective of any physical or mental condition, cause physical harm pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 675312 Page 6 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 (Resident #1; Resident#2) out of 6 residents reviewed for care plans. The facility failed to update Resident #1's care plan regarding an altercation with Resident #2 on 6/20/25.The facility failed to update Resident #2's care plan regarding an altercation with Resident #1 on 06/20/25.This failure could place resident at risk for receiving inadequate care and services.Record review of Resident#1 face sheet revealed an [AGE] year-old male initially admitted on [DATE], with diagnoses of Unspecified mood(active) disorder, Dementia (A group of thinking an social symptoms that interferes with daily functioning), , major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Non- Alzheimer's Dementia (A group of dementias that are not caused by Alzheimer's disease, the most common form of dementia. Record review of Resident #1's MDS Quarterly dated 07/31/2025 revealed Resident #1 had a BIMS Score of 04-severe cognitive impairment with behaviors of inattention and disorganized thinking, depressive mood and at times felt isolated. Resident #1 needed partial to moderate help with toileting and dressing ADLs. Resident #1 was able to transfer to toilet and chair with touch assistance. Resident #1 was able to walk up to 50 feet with two turns with moderate assistance. Resident #1 was diagnosed with hypertension and Non- Alzheimer's Dementia (A group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #1's Care Plan date 04/21/25 revealed Resident #1 expressed little activity involvement related to activity intolerance date Initiated: 04/21/2025 Revision on: 06/23/2025 Resident #1. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Resident #1 has Impaired cognitive function/ dementia or impaired thought processes related to Dementia. Care includes redirection and supervion as needed. Initiated 06/20/25 and revised on 06/24/25. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Resident #1 has impaired cognitive function/dementia or impaired thought processes related to dementia. Date Initiated: 07/31/2025 Revision on: 08/19/2025. Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.) and document per facility protocol. Date Initiated: 04/21/2025 Revision on 04/22/2025.Record review of Resident #1's progress notes dated 06/20/25 written by the Social Worker revealed Resident #1 was seen being confrontational with another resident. Social Worker stepped in and attempted to redirect and stop the two, as other staff came to aid as well. In the mist of the confrontation Social Worker witnessed Resident #1 with the small container in his hand making contact with the Resident #1. Residents separated quickly. Review of Resident's #1's progress note dated 06/20/25 written by LVN A revealed This nurse heard some commotion coming from dining room area and then social worker started yelling for someone to come and help. Upon entering dining room, I saw both residents being separated from one another. After head-to-toe assessment [Resident #1] had no 675312 Page 7 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few apparent injuries at this time. [Resident #2} also denied any pain RP, and MD called and notified of the altercation. Resident assed for pain, new skin injuries (none noted), vitals taken, RP and MD called and made aware of situation. Progress note dated 06/20/2025 written by DON revealed DON called into dining room due to resident-to-resident altercation. Other employees had already separated both residents. Resident #1 appeared upset and head- to- toe was immediately completed, no skin issued noted. MD and RP was notified by charge nurse LVN A. Review of Resident #1's progress notes dated 06/21/25 written by RN B revealed Resident #1 was observed in dining room this morning and continues to show aggression to another resident by voicing for other resident to not get near him. The resident was easily redirected at this time. Staff aware of situation, usually starts at mealtimes when both residents are in dining room. Care is ongoing and was safety maintained the RP was made aware. Progress note dated 06/21/25 revealed CNA reported she had to remove other residents from Resident #1 table due to he was getting upset and becoming angered. Residents separated and no other issues noted.Record review of Resident #1's incident report conducted by the Administrator/Abuse Coordinator dated 06/20/2025 revealed At approximately 4:30 PM on June 20, 2025, social worker was walking down the hallway when she heard a commotion coming from the dining hall. Upon entering, she observed [Resident #1] standing over [Resident #2]. [Resident #2] then pushed [Resident #1] causing him to stumble backward [Resident#1] quickly regained his balance, reached for a small plastic vase on the table, and struck Resident #2 on the head. At that time, nursing staff and facility management arrived on the scene and successfully intervened, separating the two residents. RP notified NP notified, MD notified. A head-to toe assessment and psychosocial assessment were completed for both residents. [Resident #1]and [Resident #2] were placed on 15-minute checks to ensure safety. [Resident #1] was referred to psych services for further evaluation, and [Resident #2] continues under his existing psych services. MD cleared both residents to come off 15-minute checks and return to the regular facility monitoring on 06/26/25. Record review of Resident #2's Face sheet revealed a [AGE] year-old male initially admitted on [DATE] with diagnosis of Mood Disorder (A mood disorder a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior); peripheral vascular disease( A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); Hypertension( A condition in which the force of the blood against the artery walls is too high); acquired absence of right left below knee; and Non- Alzheimer's Dementia (a group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 09-moderate cognitive impairment and needed some assistance with all ADL's. Resident #2's MDS also revealed disorganized thinking was a behavior continuously present and did not fluctuate. Resident #2's resident mood interview revealed symptoms presence of feeling down, depressed, or hopeless. Resident #2's behavioral symptoms revealed verbal behavioral example given of threatening others, screaming at others, cursing at others, which occurred 1 to 3 days. Resident #2's other behavioral symptoms not directed toward others occurred one to three days. Rejection of care was present 1 to 3 days. Resident #2's MDS revealed he needed moderate to substantial help with toileting, showering, lower body dressing and putting on and taking off footwear. Resident #2's MDS used a manual wheelchair. Record review of Resident #2's Care Plan date initiated 06/18/25 revealed, Resident #2 is at risk for activity intolerance related to major depressive disorder, severe with psychotic symptoms, mood disorder initiated on 12/16/2024 revised on 02/15/2025. Resident #2's care plan revealed has a behavior problem of being accusatory related to major depressive disorder, severe with psychotic symptoms, and mood disorder if reasonable, discuss the resident's behavior. Resident #2 care plan revealed Explanation and 675312 Page 8 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reinforcement as to why behavior is inappropriate and/or unacceptable to the resident. Refer to Psych services as needed Initiated on 02/17/2025 Revision on 03/24/2025. Resident #2 care plan revealed he had the potential to be verbally and physical aggressive related to poor impulse control and intervention was to administer medications as ordered and monitor and document for side effects and effectiveness initiate on 12/13/2024 and assess resident's understanding of the situation. Resident #2 care plan revealed to allow time for the resident to express self and feelings towards the situation initiated on12/13/2024 and the interventions were for a psychiatric/psychogeriatric consult as indicated. The DON called into dining room due to a resident-to-resident altercation. Other employees had already separated both residents. Resident #2 was noted with a scratch to left side of head, a scratch and small blood blister to his right hand. Resident #2 refused full head to toe. MD and RP were notified by charge nurse LVN E. And the SW to follow up with psych. Record review of Resident #2's progress notes by the nurse LVN E dated 06/20/2025 revealed the nurse was at the nurse's station and heard someone call for help from the dining room. When the nurse got to the dining room it was noted the resident had an altercation with another resident, employees had already separated the residents, and Resident #2 was being wheeled out of dining room. Resident#2 had not complained of pain or discomfort voiced and tried to do head to toe assessment resident refused. LVN E did note the resident had a small scratch to top of his right-hand, a small blood blister between his index finger and thumb, a small scab like area to left side of forehead. The MD informed. Resident #2 had new orders for UA, CBC, and CMP. The orders were noted, and the resident was also started on every 15 min frequent monitoring to prevent any further incidents. Record review of Resident #2 progress notes dated 06/20/25 revealed the DON was called into the dining room due to a resident-to-resident altercation and other employees had already separated both residents. Resident #2 was noted with a scratch to the point where left side of head, scratch and small blood blister to right hand. Resident #2 refused a full head to toe and the MD and RP were notified by the charge nurse LVN E and the social worker was to follow up with psych. Resident #2 progress notes dated 06/20/25 revealed and the social worker noted Resident #2 was seen being confrontational with another resident and the social worker stepped in and attempted to redirect as other staff came to aid as well and the PCS was notified. Record review of Residents #2 progress notes dated 06/23/25 Resident #2 was being monitored every 15 minutes for an altercation with another resident. Resident # 2 progress notes dated 06/23/2025 revealed team members were keeping the Resident #1 and Resident#2 separated so there was no altercation.In an interview with on 08/20/25 at 6:00pm The ADON stated the IDT team was responsible for the entry any new information to the care plans like change in condition and incidents. The SW was responsible for any behavior updates for each resident's care plan. The importance of updating the care plans is to ensure the resident is getting the appropriate care and the documentation of any change in condition and new orders from the physician are implemented. The ADON could not say why the altercation between Resident #1 and Resident #2 was not documented,. The preventive measure of the 15 min checks for each resident was implemented, and the preventive measure of keeping the two residents apart so that another incident did not occur between the two residents were not documented in the care plan interventions as well. In an interview on 09/20/25 at 9:23 AM the DON stated the nurse managers, ADON, and DON were responsible for updating the care plan for the residents. The DON stated the social worker is responsible for the behavior updates. The DON stated the team was documenting the falls with the intervention and incidents documented. The DON stated social worker and IDT as a whole are responsible for updating care plans for falls, incidents or any significate changes. The DON stated any changes in condition or incidents are discussed as a team and documented. The DON stated there was no 675312 Page 9 of 10 675312 08/20/2025 Palma Real 1220 Loop 459 Mathis, TX 78368

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few updates or interventions for the care plans for these two residents and could not say why the care plans were not updated for Resident #1 and Resident #2. The DON stated will do in-service with IDT team ensure all documentation of any the change of condition and an incident of any type occurs is entered into the care plan with the interventions. The DON stated the incident was not an abuse allegation because both residents had dementia and was reported to the abuse coordinator. Resident #1 stays in his room seldomly comes out and Resident #2 stays on his side of the facility and close to room and the staff keeps an eye on him as he was a fall risk. 675312 Page 10 of 10