Health inspection·September 3, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure the resident's right to be free from abuse for 2 (Resident #45 and Resident #23) of 2 residents reviewed for abuse, in that: On 08/29/2025, the facility failed to ensure that Resident #45 was not punched in the face by Resident #23, resulting in injury to the face.This failure resulted in injuries to Resident #45.Resident #45Record review of a face sheet dated 09/03/2025 revealed Resident #45 was [AGE] years old and was admitted on [DATE] with a primary diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, and other pertinent diagnoses including cognitive communication deficit and mood disorder due to known physiological condition with major depressive-like episode.Record review of Resident #45's MDS dated [DATE] reflected a BIMs score of 15. The residents mood interview revealed he had felt down, depressed or hopeless for several days (2-6 days) over the last 2 weeks.Record review of Resident #45's care plan, last reviewed on 05/29/2025, revealed the following care areas: Potential for psychosocial well-being problem with interventions including consult with psych services, when conflict arises- remove residents to a calm safe environment and allow to vent/share feelings.Potential to demonstrate verbally abusive behaviors and becomes very loud and verbally aggressive if he does not get his way. Various interventions included analyze and document triggers and what de-escalates behavior, assess resident's understanding of the situation and allow resident to express self and feelings towards the situation, notify the charge nurse of any abusive behaviors, psychiatric/psychogeriatric consults, and when the resident becomes agitatedintervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, ensure all residents involved are safe and staff to walk calmly away, and approach later.Record review of Resident #45's progress note dated 08/28/2025 at 18:34 (6:34PM) reflected: Resident was complaining about having verbal disagreement with his roommate about the noise both of them were making disturbing each other, upon asking both the resident about the situation, both were blaming each other about the noise statement. Advised them to be calm and issue resolved for now.Record review of Resident #45 skin assessment following the incident dated 08/29/2025 revealed the resident had skin tear on the right side of upper chest bone and right wrist.Record review of Resident #45 psychological services progress note dated 08/29/2025 reflected: (Resident #45) and therapist met. (Resident #45) apparently had a physical altercation with his roommate. (Resident #45) was still upset and reported that he did not hit his roommate but that he was struck by the roommate. It was reported the (Resident #45) through a board . Overall, he is not a danger to others but is upset that his roommate attacked him. Record review of a written interview summary from the provider investigation report, dated 08/29/2025, of Resident #45's statement reflected: Resident #45 reported that he was in bed and attempting to get up to use the bathroom when Resident #23 began yelling at him for Page 1 of 5 675779 675779 09/03/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0600 Level of Harm - Actual harm Residents Affected - Few being too noisy. Resident #45 stated that he informed Resident #23 he was simply getting up to go to the bathroom. He alleged that Resident #23 then picked up his wheelchair and threw it at him, followed by hitting him in the mouth. Resident #45 further stated Resident #23 also threw water at him. According to Resident #45, both residents were yelling when a nurse entered the room and witnessed Resident #23 strike him in the stomach. Resident #45 added that the nurse was also aware water had been thrown on him, as he had to change his shirt due to it being wet.An interview on 09/03/2025 at 5:04PM with Resident #45 revealed anytime he was moving around the room, Resident #23 would go crazy when he made a noise. He said Resident #23 had only been his roommate for a few days and had not really discussed Resident #23 prior to the altercation. Resident #45 explained he got hit in the mouth by Resident #23's fist and hit in the chest; he further stated he was only injured on the mouth had a few scratches on his chest. Resident #45 stated Resident #23 hit him because he was making too much noise in the room when he was moving his wheelchair around the room. He further explained Resident #23 told him to quit making noise, and anytime Resident #45 made a noise, Resident #23 would bang on the wall. He said Resident #23 then rolled his wheelchair at Resident #45 really hard and it hit his leg. Resident #45 said he picked up his sliding board and raised it up (to intimidate), but never threw it at Resident #23. He said Resident #23 threw water at him and he [NAME] it back at Resident #23. Resident #45 said Resident #23 followed him out of the room and punched him one time on the mouth. Resident #45 said he had not had any issues since the altercation and stays away from Resident #23. He said felt safe at the facility and lets staff know if he had issues. Resident #23Record review of a face sheet dated 09/03/2025, revealed Resident #23 was a [AGE] year-old male admitted on [DATE] with primary diagnosis of chronic combined systolic (congestive) and diastolic (congestive) heart failure and other pertinent diagnoses of bipolar disorder, current episode depressed, severe, with psychotic features, and intermittent explosive disorder.Record review of Resident #23's MDS dated 08/29/ 2025 reflected a BIMs score of 15.Record review of Resident #23's care plan initiated on 08/28/2025 revealed resident requires anti-psychotic medications (Seroquel) related to explosive personality disorder and bipolar disorder (date initiated: 08/28/2025). Interventions included monitoring effectiveness of medication, monitor/record occurrence of for target behavior symptoms and document per facility protocol, and Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications.Record review of Resident #23's clinical history from the prior facility dated 8/22/2025, revealed Resident #23 was involved in altercation with another resident on 07/24/2025. He was injured by the other resident, admitted to having a verbal confrontation with the other resident, and denied any physical altercation.Record review of Resident #23's history and physical dated 8/28/25, reflected: admission 8/26/25: The patient is a [AGE] year old Male with below PMH who presents to [facility name] from (previous facility) for LTC. All available external records including labs and imaging have been reviewed and are summarized as part of the following HPI. Once stabilized and arrangements were made, the patient was transferred to [facility name] for further medical care and rehabilitation. Record review of a written interview summary from the provider investigation report, dated 08/29/2025, of Resident #23's statement reflected According to Resident #23, the incident began when Resident #45 was in the bathroom making loud noises, reportedly banging something against the wall. Upon exiting the bathroom, Resident #23 asked Resident #45 to lower the noise level, explaining that he was trying to sleep. Resident #23 reported that Resident #45 responded with verbal aggression, making disparaging remarks about Resident #23's (hair and personal items), and allegedly stating that these attributes made him gay. Resident #23 further stated that Resident #45 then picked up a sliding board from the bed attempted to swing it at him. Resident #23 used a curtain to block 675779 Page 2 of 5 675779 09/03/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0600 Level of Harm - Actual harm Residents Affected - Few the object. Following this, Resident #23 stated Resident #45 threw a glass of water of him, which he again deflected using the curtain. Mr. [NAME] then reported that Resident #45 tipped his wheelchair backward and exited into the hallway. Resident #23 followed and struck Resident #45 in the mouth with a closed fist.Observation on 09/03/2025 at 1:57PM revealed Resident #23 dressed, groomed, and sitting outside in his wheelchair. Resident seemed relaxed, no concerns of injuries nor interactions with other residents. During an interview on 09/03/2025 at 2:07PM with Resident #23, he stated Resident #45 went crazy and tried hitting Resident #23 with his sliding board and Resident #23 blocked it with the privacy curtain. He further stated Resident #45 tried throwing water at him and he blocked that with the privacy curtain. Resident #23 said he did punch Resident #45 in the mouth. Resident #23 stated the altercation happened because Resident #45 was in the bathroom slamming something against the wall. He said he was in bed and Resident #45 came into the room screaming. Resident #23 said he did not say anything to Resident #45 and he was screaming about making noise. He explained after the nurse took Resident #45 to the hall, he was insulting Resident #23 about his hair and personal items. Resident #23 said he did not get hurt, may have hit his own arm a little. Since the incident, Resident #23 said he had not had any issues, had a good roommate, felt safe, and was receiving the care he needed. An interview with the DON on 09/03/2025 at 2:04PM revealed resident to resident altercation happened over night and LVN A was the nurse working had heard the residents in their room being loud and LVN A went to the room and removed Resident #45 from the room, and he was in his wheelchair. The DON stated Resident #23 came out of the room in his wheelchair after Resident #45 and punched him. She explained she had thought Resident #23 was the alleged perpetrator, but Resident #45 admitted to psych about his involvement with the sliding board. The DON stated police were called and both residents were cited with disorderly conduct. She further discussed that Resident #23 was a new resident and came from facility where he was involved with a resident-to-resident altercation but was not the aggressor, and he was not happy about the outcome and wanted to leave that facility; Resident #45 has been at the facility for a while and he did not get along with any roommates. An interview on 09/03/2025 at 2:24PM with the ADON revealed she spoke with Resident #45 and Resident #23 about the altercation. She said Resident #45 stated he got up to use the restroom during the night and Resident #23 was cussing and yelling because he was making too much noise. She said Resident #45 stated Resident #23 threw his wheelchair at him and then threw water at him. The ADON said Resident #45 then came out to the hall with the nurse and Resident #23 followed him out, where Resident #45 was punched in the face and stomach. The ADON said Resident #23 stated Resident #45 was using the restroom and banging on stuff in the restroom and he asked Resident #45 to be quiet, and then Resident #45 tried hitting Resident #23 with his sliding board and then threw water at him. She said Resident #23 stated he blocked both with his privacy curtain. The ADON explained that while she was not present, Resident #23 was in bed at the time of and could not have grabbed the privacy curtain (based on distance from bed to privacy curtain). She then stated that Resident #23 got into his wheelchair and went and punched Resident #45. She explained following the altercation, police were called and both residents were given citations equal to jail time. Both residents were separated, rooms were changed, and continuous monitoring had been done. The ADON stated that because Resident #45 was punched in the face, he had neuro assessments done and he had some scratches on his chest that had been treated. An interview on 09/03/2025 at 4:10PM with the ADM revealed she was told about the resident-to-resident altercation on 08/29/2025 after it occurred. She said Resident #45 can be contentious and he bothered Resident #23. She further stated things were thrown and then punches; both residents were given citations by the police. The ADM stated she does not recall Resident #45 having altercations with 675779 Page 3 of 5 675779 09/03/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0600 Level of Harm - Actual harm Residents Affected - Few other roommates, but he gets his way by being loud because he wants a room to himself. The ADM explained she knew Resident #23 had a history of a resident-to-resident altercation at the previous facility but that he was not the aggressor; he didn't like the outcome at the other facility, so he wanted to move. The ADM stated when determining room assignments, it was based on type of care resident's need and type of pay (Medicare, Medicaid, private, hospice, etc.), and the facility was down (limited option) to Resident #45. She explained Resident #45 recently moved to hall 400 due to not getting along with previous roommate in hall 200, and Resident #23's health condition was not suitable for hall 200 since it was for heavier (more severe) health conditions. She said she was not aware of any other signs of the residents not getting along before the altercation. An interview on 09/03/2025 at 4:30PM with the SW revealed she found out about the altercation when she came to work for her next shift. She said she talked to Resident #45 and his psychologist, and she thought he was the aggressor. The SW said the altercation probably could have been avoided because Resident #23 was easily agitated, and Resident #45 said he was not afraid of him but did not like him. She said she talked with Resident #23, and he did not like being at the facility and was thrown out of the previous place. She explained Resident #45 was probably angry at having a roommate and Resident #23 admitted he wanted his own room. The SW further discussed before the altercation occurred, Resident #45 talked to CNA C about Resident #23 and felt like he could not do anything in his room. The SW explained she was working with the residents following the altercations. She said Resident #45 will continue current care and psych services and referred Resident #23 for psych services. She stated she had been helping Resident #23 become accustomed to the facility and help meet his needs. An interview on 09/03/2025 at 4:52PM with CNA C revealed Resident #45 told her he had been fixing his armrest on his wheelchair and it made loud noises, and Resident #23 started banging on the wall. She said she asked Resident #23 if he had been upset and he said he was fine. CNA C said she told a nurse about the residents, but she had never heard them argue.An interview on 09/03/2025 at 5:59PM with the DON revealed no one told her Resident #45 had told staff he was not getting along with Resident #23. She said she saw the nurse's note (08/28/2025) the next morning on 08/29/2025 and educated the nurse to tell her about it because if something happens like that and was explosive, then staff needs to separate the residents. She further stated if she would have known, she would have separated them. The DON explained Resident #45's loud and she can hear him talk from her office. She explained she thinks Resident #45 was just loud with his wheelchair and that was what started the altercation. She said there was no physical contact in the room, just verbal. The DON said LVN A went to room and had Resident #45 come out of the room, and she turned around to walk to her cart when Resident #23 came out of the room and hit Resident #45 in the face. The DON explained Resident #45 cannot keep a roommate because he was miserable. She said Resident #23 ended up with Resident #45 because they were both male, similar age and background. The DON further explained all clinical history was reviewed for Resident #23; the only information they received was sent by corporate. She stated they knew Resident #23 was involved with a resident-to-resident altercation at the previous facility but was told the other person was the aggressor. The DON said they received a very brief history about Resident #23, and if she had seen he had an altercation history, she would not have taken him. She further explained the facility received Resident #23's history and physical and there was no information about aggressive episode, trauma informed care, or his behaviors. Since the altercation, the DON said a psych referral had been done but he will have to see psych between dialysis appointments, and they were working with Resident #23 to help meet needs with activities of interest to him. The DON stated she knew how Resident #45 was, he would yell and insult other residents but would not hit them. She explained Resident 675779 Page 4 of 5 675779 09/03/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0600 Level of Harm - Actual harm Residents Affected - Few #45 continued psych services and staff had been doing neuro assessments on him due to the injury on his face. Attempted interviews on 09/04/2025 at 9:38AM and 09/05/2025 at 12:36PM with LVN A, with no answer.Record review of the facility's Abuse and Neglect Policy, revised 3/29/18, reflected: The resident has the right to be free from abuse. This includes but is not limited . any physical . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.Definitions1. Abuse: Abuse is 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. 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.5. Physical Abuse: Includes, hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. 675779 Page 5 of 5