Health inspection·December 16, 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 protect the residents' right to be free from verbal and physical abuse for 1 (Residents #4) of 4 residents reviewed for abuse. The facility failed to ensure residents were free from physical abuse when Resident #2 wandered into another resident's room, punched Resident #4 on the arm, attempted to hit and started cursing when Resident #4 told Resident #2 that he was in the wrong room. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included:Resident #4Record review of Resident #4's Closed Records reflected an admission Record admission Date 11/24/25. Resident was discharged [DATE]. Review of History and Physical dated 12/02/25 for Resident #4 revealed [AGE] year-old female with past medical history of CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), Diabetes Mellitus (a chronic condition where the body does not produce enough insulin or cannot use insulin effectively), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), Hypothyroidism - thyroid gland does not produce enough thyroid hormones, which control body's energy use causing many functions to slow down leading to fatigue, weight gain, feeling cold, and dry skin). Review of admission MDS dated [DATE] for Resident #4 revealed, clear speech, makes self-understood, understands others, BIMS Score 13 (cognitively intact). Independent with indoor mobility with walker. Review of Care Plan dated 12/05/25 for Resident #4 revealed, Resident to Resident altercation. Resident struck by another resident while in room. Aggressor removed immediately. No visible injuries. Interventions: Provide emotional reassurance and maintain therapeutic communication. Review of Progress Note dated 12/05/25 for Resident #4 written by Nurse Practitioner revealed, today patient has been seen and evaluated with the charge nurse in charge of the patient. During today's rounds, patient was heard calling out for help. Upon entering room, it was observed that another resident had entered her room unintentionally. The resident appeared confused and was reportedly looking for his own room. The patient stated that the other resident hit her in the left arm and attempted to kick her. Patient described feeling startled by the encounter. A full evaluation was conducted at bedside, alert oriented to person, place, and time. Upon physical exam left arm, now swelling, no redness, no bruising, no tenderness on palpation, full ROM without pain, no visible signs and symptoms of trauma or injury. Distress Assessment: Patient verbalized she was OK and denied ongoing pain or discomfort. She stated that she was primary startled by the incident. Record review of Resident #2's Closed Records reflected an admission Record with the Original admission Date as 02/16/2023 and re-admission Date as 02/10/25. Resident was discharged [DATE].Review of Hospital paperwork from Geriatric Behavioral Unit (GBU) dated 12/05/25 for Resident #2 reflected, admission date 12/05/25 and discharge date [DATE]. History & Physical dated 12/05/25 revealed [AGE] year-old male Page 1 of 20 675831 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transferred to Geriatric Behavioral Units from the ER, brought in via EMS, from nursing home for violent behavior and GBU evaluation. Reason for admission: danger to others, danger deterioration. History and Present Illness: According to ED notes: He was recently discharged on 12/01/25 after being admitted on [DATE] for similar reasons of aggression with staff and residents at the nursing facility. This is his 3rd admission this year, the first one in February of this year. Patient was confused, does not acknowledge behaviors that brought him here. Denies mood swings, hallucinations. The patient is unable to answer questions. Review of systems: no anxiety, no depression. Summary Statement and Safety Plan: Due to these chronic acute, protective factors, I do find this individual to be at a high risk of hurting themselves or others. Will remain in structured environment. On-going psychiatric assessment and close monitoring. Maintain inpatient care to ensure patient safety and stabilization. Record review of Resident #2's History & Physical dated 04/03/25 revealed [AGE] year-old male with past medical history of vascular dementia with mood disturbance (A condition where brain damage from poor blood flow causes issues with thinking and memory, along with significant emotional changes like depression, anxiety and extreme mood swings), recurrent depressive disorder (Repeated episodes of feeling deeply sad, lost interest in things, have no energy and experience other symptoms like sleep, appetite changes, and might have periods of normal moments in between the episodes before the next depressive episode comes back), generalized anxiety disorder (constantly feel anxious or on edge about everyday things. Even when there's little reason to and it's hard to turn now or control, leading to physical symptoms like muscle tension, fatigue and trouble sleeping, making daily life feel overwhelming), and impulse disorder (A struggle to stop one's self from doing things, you shouldn't, leading to sudden actions like anger outburst, stealing or binge eating, even when they cause problems to the individual or others). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed BIMS Score 3 (severe cognitive impairment), functional limitation in range of motion to upper and lower extremities, Mobility device - wheelchair; requires substantial/maximal assistance with toileting hygiene, lower body dressing and putting on/taking off footwear; dependent with showers; partial/moderate assistance with personal hygiene. Set up assistance with sit to lying, sit to stand, chair/bed transfer, and tub/shower transfer and once seated in wheelchair, the ability to wheel at least 150 feet in a corridor or similar space. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), anxiety, depression, vascular dementia with mood disturbance and recurrent depressive disorder. High-Risk Drug Use - antidepressant, and anticonvulsant. Record review of Resident #2's Care Plan revealed: -Care Plan revised on 12/05/25 The resident has potential to be physically aggressive, related to dementia and poor impulse control. Interventions: In service direct care staff on residence behaviors and how to detect escalation. Analyzed times of day, places, circumstances, triggers and what the escalates behavior and document. Administer medications and labs as ordered. Monitor for side effects and effectiveness and notify physician of effectiveness. Assess and address for contributing sensory triggers as they occur. The residence triggers for physical aggression are to be monitored and identified so they can be used to deescalate the situation. When the resident becomes agitated, intervene before agitation escalates. -Care Plan revised on 09/23/25 The resident has a mood problem r/t anxiety, agitation. Interventions: Assist the resident in developing/providing the resident a program of activities that are meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. Behavioral health consults as needed. Administer medications as ordered. Monitor/document for side effects and effectiveness. -Care Plan revised on 06/19/25. Resident is on anticonvulsant therapy r/t impulse disorder. Goal: Revised 11/04/25. Target Date: 02/02/26. Resident will be free of seizure 675831 Page 2 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activity through the next review. Interventions: Protect from injury if seizure occurs. Pad siderails as needed to prevent injury. Monitor for signs of warning prior to seizures. Give meds per order, monitored labs -report abn's to physician. Document seizure in clinical record.-Care Plan revised on 04/21/25. The resident has impaired cognition function or impaired thought processes r/t Dementia. Goal: Revised 11/04/25. Target Date: 02/02/26. The resident will be able to communicate basic needs on a daily basis through next review. Interventions: Discussed concerns about confusion, disease process, Nursing Home placement with resident and family. Communicate with resident and family regarding resident's capabilities and needs. Administer medications as ordered. Monitoring document side effects and effectiveness.-Care Plan revised on 04/02/25. The resident has potential to be verbally aggressive r/t Dementia. Goal: Revised: 11/04/25. Target Date: 02/02/26. The Resident will demonstrate effective coping skills by next review. Interventions: Assess resident's coping skills and support system. Assess and anticipate resident's needs: food, thirst, toilet needs, comfort level, body positioning, pain etc. Analysis of key times, places and circumstances, triggers and what deescalates behavior and comfort. Administer medications as ordered. Monitored document side effects and effectiveness.-Review of Physician Order Summary Dated 12/15/25 for Resident #2 revealed, 12/01/25 Behavior Management Provider to provide psychiatric and psychosocial services evaluate and treat as warranted. Pharmacy: Start Date: 12/01/25 Benzgalantamine Gluconate Oral Tablet Delayed Release 10 MG (Benzgalantamine Gluconate) Give 1 tablet by mouth two times a day for Dementia. Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for Dementia. Start Date: 12/01/25 Hydroxyzine Pamoate Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety for 14 Days. Memantine HCl Oral Tablet 10 MG give 1 tablet by mouth two times a day for Alzheimer's disease. Start Date: 12/01/25 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml by mouth two times a day for behaviors. -Review of Physician Progress note written by Nurse Practitioner on 12/05/25 for Resident #2 revealed, Patient is being seen today s/p return to facility from GBU for an aggressive episode towards another resident in the facility. Today I witnessed patient in another resident's room noted with aggressive behavior, resident placed on 1:1 with facility staff and is pending to be sent out to GBU for reevaluation of aggression and his behavioral episode. Plan: Send to GBU for evaluation of aggressive behavior. Social Services for discharge planning. Review of contracted Behavior Health Clinical Treatment Plan dated 12/02/25 for Resident #2 revealed, Resident had cognitive ability to establish a verbal therapeutic relationship with therapist. Behavior and emotions improve in response to participation in therapy. Patient is an [AGE] year-old male who was admitted to the facility on [DATE] from the hospital. Medical records note vascular dementia. Patient referred for psych and Med management services due to anxiety, irritability, agitation, verbal physical aggression. Staff reports patient can be occasionally irritable and critical. Medical History: Alzheimer's Disease, Dementia. Resident has anxiety, depression, disorientation, emotional withdrawal. Moderate Cognitive Decline. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, Primary Treating Dx: Impulse Behavior. Secondary Treating Dx: recurrent depressive disorder. Insomnia, Delusional Disorder, Vascular Dementia, and unspecified dementia with other behavioral disturbances. Reason for Referral: Anxiety Disorder, Irritability, Anger, Verbal Aggression, Physical Aggression. Staff members were instructed to promptly inform the provider of any changes in the patient's mental status or the appearance of new or worsening symptoms, including confusion, mood alterations, anxiety, changes in appetite, or sleep issues. Oriented to person. Thought Content: Delusions. Insight: Poor. Judgement: Poor. Resident is non-verbal. Due to dementia, expectations are that the patient will most likely experience loss of 675831 Page 3 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few function, refusal of care, behaviors (including wandering, agitation, aggression) changes in weight and further decline of cognition. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, the patient voices no symptoms of depression, anxiety, changes in appetite, sleep disturbances, or psychosis but has dementia related agitation and psychosis. The patient was sent to GBU and returned with no change in orders. The writer made changes upon his return and is closely monitoring the changes and behaviors. Staff observed no aggression or agitation but is back at baseline in which the patient refuses showers and certain nursing care but does not get physical with redirection. Cognitive impairment. Oriented to person. Thought Content: Delusions. Labs reviewed: UTI. -Review of Nurse's IDT notes from August 2025 - December 2025 revealed, Resident #2 frequently propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, pushed residents out of his way as he propelled himself up and down the resident halls. -Review SBAR Communication Form dated 12/05/25 for Resident #2 revealed, Behavioral Symptoms started on 12/05/25 and have gotten worse. During an interview on 12/11/25 at 2:40 AM with DON revealed, Resident #2 was alert and oriented to person, was able to answer simple questions, used a wheelchair for mobility, propelled his wheelchair with his feet up and down the resident halls and constantly went into other resident rooms and resisted redirection to leave the room because he thought that it was his room. She said the resident required close supervision and redirection to keep him from going into other resident rooms. She said the resident had delusions, sundown, and would push the other residents out of his way when he wheeled himself in the resident halls, refused to shower, swearing at staff when attempts were made to provide daily care, at times suspicious of others, demanding, and anxiety. She said the resident could not have a roommate because he preferred to be by himself, would cuss, throw water at his roommates and would ask them to leave because it was his room. She said the resident spoke some English but preferred to speak in Spanish and was able to answer questions. She said the resident had multiple medication adjustments and was taking Valproic Acid for behaviors and several medications for his dementia. She said that in the last incident on 12/05/25, they heard Resident #4 yelling for help and upon entering the room, found Resident #2 in her room and she was telling him to leave because it was not his room. She said Resident #4 reported he had punched her in the arm and was resisting leaving the room. She said Resident #2 was placed on 1:1 to keep him from going into other resident rooms on that day, until he was sent to the GBU. The DON said the facility staff tried to provide close supervision and re-direction to Resident #2 while they provided care to the other residents. During an interview on 12/11/25 at 2:55 AM with LVN Charge Nurse B in the 200 Hall revealed, Resident #2 was re-admitted from the hospital a couple of weeks ago to the 200 Hall. She said he was occasionally oriented to person and place, and he thought he was at home. She said the resident had limited range of motion to one arm, was incontinent of bowel & bladder, was able to stand up with assistance, and needed assistance with dressing. She said he constantly propelled his wheelchair with his feet up and down the halls looking for his room. She said that on the date of the incident on 12/05/25 she and the Nurse Practitioner had heard Resident #4 yelling for help. She said that when they had entered the room, Resident #2 had one hand in a fist, and she said he had hit her, and he was pulled away. She said Resident #4 had reported she was telling Resident #2 that he was in the wrong room, and he had started cursing and had punched her in her arm. She said the Nurse Practitioner had assessed Resident #4 and had no apparent injuries. She said, I have heard from other staff say that he goes into other resident rooms. I had never seen him go into other resident rooms until the day of the incident on 12/05/25. During an interview on 12/12/25 at 3:07 PM with RN ADON C revealed that on 12/05/25 she had been notified by LVN Charge Nurse B at 675831 Page 4 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few approximately 12:50 PM, that Resident #2 had been placed on 1:1 to prevent Resident #2 from leaving the room and going into other resident rooms until he was transferred to the GBU for evaluation of aggressive behavior. She said Resident #2 had refused to allow the staff to assess him and did not allow the staff to get close to him. She said EMS was called and he was sent to the hospital for evaluation of his aggressive behavior. She said Resident #2 was oriented to person and at times to place, propelled his wheelchair with his feet all over the facility looking for his room. She said that at times he attempted to enter other resident rooms and required close supervision and redirection from the staff. She said Resident #2 used to be in the 100 Hall and had been placed in the 200 Hall upon readmission from the hospital. She said he would frequently go to the 100 Hall looking for his room. She said Resident #2 had a history of physical aggression towards other residents and staff when care was provided. She said he had punched one of his roommates on the chest and had not caused any apparent injuries. She said on another occasion he threw water at one of his roommates because he wanted him to leave the room. She said Resident #2 had been sent to the GBU for altercations with other residents, non-compliance with medications, refusing showers and labs. She said the resident toileted with assistance and ate in the main dining room. She said he was very particular to those who sat with him at the table in dining room and would leave the dining room if he did not like the residents. She said Resident #2 had a recent incident involving Resident #4. She said Resident #2 had wheeled himself into her room and when she was telling him he was in the wrong room, he had punched her in the arm and did not cause any apparent injuries. During an interview on 12/12/25 at 3:20 PM with LVN MDS Nurse D assigned to Resident #2 revealed, he was a loner, very particular who he talked to, was occasionally oriented to person and place. She said he was also very particular to the people who sat with him in the dining room and would leave the table and go to his room if he did not like the people that sat at the table with him. She said his BIMS score was 3, which meant he was severely cognitively impaired. She said he propelled his wheelchair with his feet all over the facility looking for his room and never attempted to leave the facility. She said he would at times wheeled himself into other resident rooms, thinking that it was his room. She said he frequently resisted personal care and would push the staff away and/or hit the staff when they attempted to provide daily care. She said he would also yell at the staff when care was provided. During an interview on 12/12/25 at 4:01 PM with Executive Director revealed, he had issued Resident #2 a Discharge Notice on 12/06/25 after he had been sent to the GBU, on 12/05/25 for evaluation of physical aggression. He said the reason for giving the resident a discharge notice was because he had assaulted a resident and was a threat to staff and other residents at the facility. He said Resident #2 had another incident either in January or February 2025 of this year where he kicked, punched the staff, was verbally abusive and resisted care. He said the resident also had wandering behavior and propelled his wheelchair with his feet all over the facility occasionally went into other resident rooms. He said the resident became verbally and physically aggressive when the staff attempted to redirect him. He said the resident required close supervision and redirection especially when he was around other residents. He said the resident ate his meals in the dining room and he was very particular of who sat at the table with him. He said that in the last incident on 12/05/25, Resident #2 wheeled himself into Resident #4's room, and when she had told the resident to leave because it was not his room, he had punched her in the arm. He said Resident #4 had not sustained any injuries on the day of the incident. He said that they had decided to readmit Resident #2 to the 200 Hall after he had returned from the GBU on 12/01/2025, so he could have a room to himself to prevent incidents because when they had attempted to place a roommate in his room, he would kick them or throw water at the roommates. He said that 675831 Page 5 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the interventions that they had attempted to keep him from being aggressive with residents and staff had been unsuccessful, and that is why the resident was issued a discharge notice because he was a threat to residents and staff. During an interview and record review on 12/15/25 at 11:44 AM, with DON revealed, she had followed up with the GBU today and was informed the Resident #2 had been discharged to a [NAME] Home. She said the Nurses IDT Notes only documented Resident #2 resisted care and did not document the resident propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, thinking that it was his room, did not document resident required close supervision and redirection to help him find his room. Review of the Treatment Administration Records revealed the TARs dated September 2025 through December 2025 did not document specific behaviors exhibited by Resident #2. She said the TARs did not document resident had episodes of verbal and physical aggression verbal and physical aggression towards staff when they attempted to provide care and re-direction, wandered up and down the halls looking for his room and pushed other residents out of his way, entered other resident rooms thinking it was his room and punched them and refused labs. She said the TAR did not document non-pharmacological approaches used to minimize the need for medications that addressed resident's behaviors. During an interview and record review on 12/15/25 at 12:30 PM, with LVN MDS Nurse D stated, they had morning meetings with the nurses and CNAs to report changes in condition, behaviors, changes in skin integrity. She said the staff had been trained to document behaviors in the Nurse's progress notes, CNA documentation sheets in the electronic clinical record. She said she was not aware if the nurses documented behaviors exhibited the resident and/or non-pharmacological interventions in the TARs. She said the care plan needed to be revised by the IDT after each comprehensive and quarterly MDS assessment. She did not know how changes to care plan were communicated to the staff. She said the facility did not have any documentation in the IDT notes of how often the IDT discussed resident behaviors and effect of care plan interventions. She said she had not changed the revision date on the care plan for the Risk for elopement/wandering since 4/21/25 and the interventions did not reflect the resident required close supervision and redirection to keep him from entering other resident rooms and prevent recurrence of physical aggression towards other residents. She confirmed the care plan did not document non-pharmacological interventions. She said the care plan did not address that he wheeled himself in his wheelchair up and down the halls and pushed residents out of his way. She said the facility did not have any documentation in the Care Plan dated 12/05/25 of resident triggers for physical aggression, of when and who monitored and identified triggers to de-escalate physical aggression towards other residents and staff. She confirmed the care plan interventions did not document non-pharmacological interventions to prevent physical aggression towards staff and other residents. Review of the care plan that addressed Resident #2 had mood problem r/t anxiety and agitation was last revised on 06/19/25 and did not document the resident preferred to be by himself in his room and did not like to interact with resident or staff due to easily becoming anxious and agitated. The care plan interventions did not document non-pharmacological interventions to prevent anxiety and agitation or what type of activities were provided to the resident. Review of the care plan that addressed Resident #2 was on antidepressant medication was last revised on 06/19/25. She confirmed the care plan interventions did not document non-pharmacological interventions. Review of the care plan that addressed the resident is on anticonvulsant therapy r/t impulse behavior last revised on 06/19/25 and the Goal and Interventions written on the care plan were related to seizure disorder. The care plan did not document the residents' behaviors and non-pharmacological intervention. The care plan did not document the resident was receiving psychological and psychiatric services to manage impulse behavior. Review of the care plan that 675831 Page 6 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few addressed the resident, had impaired cognitive function or impaired thought processes r/t Dementia. She confirmed the care plan interventions did not document non-pharmacological interventions. During an interview on 12/15/25 at 2:18 PM, with LVN Charge Nurse E revealed, Resident. #2 was only oriented to person, propelled his wheelchair with his feet, up and down the halls looking for his room. She said the resident, occasionally entered other resident rooms and lay in their beds. She said the resident also had verbal aggression and would swear and cuss the residents and staff when care was provided. She said the resident had a strong personality. Macho (a man who is aggressively or overly masculine, often showing an exaggerated sense of toughness, dominance, and self-assurance) and it was his way or the freeway. She said he preferred to speak in Spanish, was a loner, and get very upset if someone got in his way when he propelled himself up and down the halls. She said he was rude and short with the staff when they attempted to talk to him. She said he had been sent to the Geriatric Behavior Unit on several occasions due to punching and being confrontational with other residents and staff. She said the other residents were afraid of him and scared of being around him. She said she was not familiar with Care Plan and had never read the Care Plan interventions. She said she did not know if the CNAs were informed of the Care Plan interventions that addressed resident's behaviors. She said Resident #2 needed closed supervision, redirection and assistance to find his room. She said the resident never attempted to elope from the facility. She said, he wheeled himself up and down the halls looking for his room. During an interview on 12/15/25 at 2:35 PM, with LVN Charge Nurse F revealed, Resident #2 had been recently moved to the 200 Hall upon readmission from the hospital. She said the resident kept going to the 100 Hall looking for his room. She said the resident was only oriented to person, was confused and propelled his wheelchair with his feet up and down the halls, occasionally entered other resident rooms. She said the staff had to wheel him to his room as needed or had to remove him from other resident rooms. She said he was able to propel his wheelchair very fast and at times they could not keep up with him or keep an eye on him because they were busy doing their work. She said the resident was a loner and was territorial and did not like to have roommates. She said that when he was alone in his room and did not have a roommate, he would not have behaviors. She said he would kick and take things from his roommates. She said the resident would become verbally aggressive in the dining room if he did not like who sat at his table. He would ask the resident to move to another table, or he would leave the dining room and go to his room. She said the resident was receiving psychological services, had multiple medication changes. She said initially the medication changes work, then he will start with the same behaviors again. During an interview on 12/15/25 at 4:00 PM with CNA G, said Resident #2 was confused, oriented to person and at times was able to find his room. He said the resident propelled his wheelchair with his feet all over the facility and required close supervision and redirection because he went into other resident rooms. He said the resident mainly spoke Spanish but understood English. He said the resident was territorial, was a loner, and ate his meals in the dining room. He said he did not like to talk much to the staff, and he read the newspaper and watched TV in his room. He said resident rounds were made every two hours, and they tried to redirect Resident #2 as much as they could while they did their work. He said the resident did not like to attend group activities; he became anxious about being around people. He said the resident was Bossy and like to be in control. He said the resident refused showers. He said, With Resident #2, it's all in the approach and how you talk to him that makes him become agitated or how you ask him to assist with his personal care. He just wants to feel that he is in control. During telephone interview on 12/16/25 at 9:37 AM, CNA J said Resident #2 was confused, oriented to person. He said the resident had aggressive behavior, started yelling, swearing, and refused 675831 Page 7 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showers. He said the resident propelled his wheelchair with his feet all over the facility. During an interview on 12/16/25 at 1:30 PM with Activities Director revealed, Resident #2 was confused, liked to be by himself in his room and did not like to attend group activities. She said she provided him with books on economics, because he was an accountant and provided history books for him to read in his room. She said Resident #2 did not like to interact with others and did not like to participate in group activities. She said the resident propelled his wheelchair down the hallways and would motion with his hands for the other residents to get out of his way. She said she was not aware of residents' behaviors. During an interview and record review on 12/16/25 at 1:45 PM, with DON revealed, she said the TARs dated September - December 2025 did not document specific behaviors exhibited by Resident #2 such as verbal/physical aggression, refusal of care, refusal of labs and propelling his wheelchair up and down the halls and into other resident rooms. She said the TARs dated September - She said the facility did not have any documentation in the Care Plan dated 12/05/25 of resident triggers for physical aggression, of when and who monitored and identified triggers to de-escalate physical aggression towards other residents and staff. She confirmed the care plan interventions did not document non-pharmacological interventions to prevent physical aggression towards staff and other residents. Review of the care plan revealed MDS LVN D had not changed the revision date on the care plan that addressed Resident #2 had mood problem r/t anxiety and agitation was last revised on 06/19/25 and did not document the resident preferred to be by himself in his room and did not like to interact with resident or staff due to easily becoming anxious and agitated. The care plan interventions did not document non-pharmacological interventions to prevent anxiety and agitation or what type of activities were provided to the resident. The care plan did not document the residents' behaviors and non-pharmacological intervention. The care plan did not document the resident was receiving psychological and psychiatric services to manage impulse behavior. During an interview on 12/16/25 at 2:27 PM, the Executive Director revealed they had a change of ownership on 12/04/25. He said, So everyone was considered to be a new hire. He said they had not made copies of training records for the facility staff prior to the change of ownership and did not have documentation of the last annual training on Dementia and Behavior Management for some of the staff. He said they were in the process of completing the annual training on Dementia and Behavioral Management for the staff. He said he did not know about behaviors being addressed in care plans and nonpharmacological intervent 675831 Page 8 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents (Resident #2) reviewed for dementia care. -The facility failed to provide or address the customary routines, preferences, and choices to enhance Resident #2's well-being when he refused care, refused labs, and became physically and verbally aggressive from August 2025 - December 2025. -The facility failed to implement interventions related to behavioral issues related to dementia, when Resident #2 wandered into another resident's room, punched Resident #4 on the arm, attempted to strike and was cursing when Resident #4 told Resident #2 that he was in the wrong room. This failure could result in residents with dementia not receiving services focused on their dementia-related behaviors which placed him and other residents at risk of not receiving the necessary personal care and services and placed residents at risk of verbal and physical abuse related to wandering behavior. Findings included: Resident #4Record review of Resident #4's Closed Records reflected an admission Record admission Date 11/24/25. Resident was discharged [DATE]. Review of History and Physical dated 12/02/25 for Resident #4 revealed [AGE] year-old female with past medical history of CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), Diabetes Mellitus (a chronic condition where the body does not produce enough insulin or cannot use insulin effectively), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), Hypothyroidism - thyroid gland does not produce enough thyroid hormones, which control body's energy use causing many functions to slow down leading to fatigue, weight gain, feeling cold, and dry skin). Review of admission MDS dated [DATE] for Resident #4 revealed, clear speech, makes self-understood, understands others, BIMS Score 13 (cognitively intact). Independent with indoor mobility with walker. Review of Care Plan dated 12/05/25 for Resident #4 revealed, Resident to Resident altercation. Resident struck by another resident while in room. Aggressor removed immediately. No visible injuries. Interventions: Provide emotional reassurance and maintain therapeutic communication. Review of Progress Note dated 12/05/25 for Resident #4 written by Nurse Practitioner revealed, today patient has been seen and evaluated with the charge nurse in charge of the patient. During today's rounds, patient was heard calling out for help. Upon entering room, it was observed that another resident had entered her room unintentionally. The resident appeared confused and was reportedly looking for his own room. The patient stated that the other resident hit her in the left arm and attempted to kick her. Patient described feeling startled by the encounter. A full evaluation was conducted at bedside, alert oriented to person, place, and time. Upon physical exam left arm, now swelling, no redness, no bruising, no tenderness on palpation, full ROM without pain, no visible signs and symptoms of trauma or injury. Distress Assessment: Patient verbalized she was OK and denied ongoing pain or discomfort. She stated that she was primary startled by the incident. Record review of Resident #2's Closed Records reflected an admission Record with the Original admission Date as 02/16/2023 and re-admission Date as 02/10/25. Resident was discharged [DATE].Review of PASRR Level 1 Screening dated 12/01/2025 for Resident #2 revealed, Primary Diagnosis of Dementia, Mental Illness. Review of Hospital paperwork from Geriatric Behavioral Unit (GBU) dated 12/05/25 for Resident #2 reflected, admission date 12/05/25 and discharge date [DATE]. History & Physical dated 12/05/25 revealed [AGE] year-old male transferred to Geriatric Behavioral Units from the ER, brought in via EMS, from nursing home for Residents Affected - Few 675831 Page 9 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few violent behavior and GBU evaluation. Reason for admission: danger to others, danger deterioration. History and Present Illness: According to ED notes: He was recently discharged on 12/01/25 after being admitted on [DATE] for similar reasons of aggression with staff and residents at the nursing facility. This is his 3rd admission this year, the first one in February of this year. Patient was confused, does not acknowledge behaviors that brought him here. Denies mood swings, hallucinations. The patient is unable to answer questions. Review of systems: no anxiety, no depression. Summary Statement and Safety Plan: Due to these chronic acute, protective factors, I do find this individual to be at a high risk of hurting themselves or others. Will remain in structured environment. On-going psychiatric assessment and close monitoring. Maintain inpatient care to ensure patient safety and stabilization. Record review of Resident #2's History & Physical dated 04/03/25 revealed [AGE] year-old male with past medical history of vascular dementia with mood disturbance (A condition where brain damage from poor blood flow causes issues with thinking and memory, along with significant emotional changes like depression, anxiety and extreme mood swings), recurrent depressive disorder (Repeated episodes of feeling deeply sad, lost interest in things, have no energy and experience other symptoms like sleep, appetite changes, and might have periods of normal moments in between the episodes before the next depressive episode comes back), generalized anxiety disorder (constantly feel anxious or on edge about everyday things. Even when there's little reason to and it's hard to turn now or control, leading to physical symptoms like muscle tension, fatigue and trouble sleeping, making daily life feel overwhelming), and impulse disorder (A struggle to stop one's self from doing things, you shouldn't, leading to sudden actions like anger outburst, stealing or binge eating, even when they cause problems to the individual or others). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed BIMS Score 3 (severe cognitive impairment), functional limitation in range of motion to upper and lower extremities, Mobility device - wheelchair; requires substantial/maximal assistance with toileting hygiene, lower body dressing and putting on/taking off footwear; dependent with showers; partial/moderate assistance with personal hygiene. Set up assistance with sit to lying, sit to stand, chair/bed transfer, and tub/shower transfer and once seated in wheelchair, the ability to wheel at least 150 feet in a corridor or similar space. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), anxiety, depression, vascular dementia with mood disturbance and recurrent depressive disorder. High-Risk Drug Use - antidepressant, and anticonvulsant. Record review of Resident #2's Care Plan revealed: -Care Plan revised on 12/05/25 The resident has potential to be physically aggressive, related to dementia and poor impulse control. Interventions: In service direct care staff on residence behaviors and how to detect escalation. Analyzed times of day, places, circumstances, triggers and what the escalates behavior and document. Administer medications and labs as ordered. Monitor for side effects and effectiveness and notify physician of effectiveness. Assess and address for contributing sensory triggers as they occur. The residence triggers for physical aggression are to be monitored and identified so they can be used to deescalate the situation. When the resident becomes agitated, intervene before agitation escalates.-Care Plan revised on 11/04/25 Resident has a behavior problem related to smears, fecal matter and restroom and refuses to change dirty clothes. Interventions: Educate the resident on successful coping and interaction strategies. Assist the resident to develop more appropriate methods of coping and interacting. Encourage the residents to express feelings appropriately. Provide opportunity for positive interaction, attention. Administer medications as ordered. Monitoring document side effects and effectiveness. -Care Plan revised on 09/23/25 The resident is resistive to care r/t refuses showers. Interventions: If possible, negotiate a time for ADL's so the resident participates 675831 Page 10 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the decision-making process. Return at the agreed time. Give clear explanations of all charities prior to. And as they occur during each contact. Allow the resident to make decisions about treatment regimen. To provide a sense of control. -Care Plan revised on 09/23/25 The resident has a mood problem r/t anxiety, agitation. Interventions: Assist the resident in developing/providing the resident a program of activities that are meaningful and of interest. Encourage and provide opportunity for exercise, physical activity. Behavioral health consults as needed. Administer medications as ordered. Monitor/document for side effects and effectiveness. -Care Plan revised on 06/19/25 The resident uses antidepressant medication r/t depression. Goal: Revised 11/04/25. Target Date: 02/02/26. The resident will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions: Monitor/document/report PRN Adverse reactions to antidepressant therapy, change in mood, behavior, cognition, hallucinations, delusions, social isolation, withdrawal, decline in ADLs, continence, gait changes, rigid muscles, balance problems, movement problems, tremors, falls, insomnia, dry mouth and dry yes. Educate the resident about risk and benefits and side effects of antidepressant. Administer antidepressant medications as ordered. Monitor and document side effects and effectiveness Q Shift.-Care Plan revised on 06/19/25. Resident is on anticonvulsant therapy r/t impulse disorder. Goal: Revised 11/04/25. Target Date: 02/02/26. Resident will be free of seizure activity through the next review. Interventions: Protect from injury if seizure occurs. Pad siderails as needed to prevent injury. Monitor for signs of warning prior to seizures. Give meds per order, monitored labs -report abn's to physician. Document seizure in clinical record.-Care Plan revised on 04/21/25. The resident has impaired cognition function or impaired thought processes r/t Dementia. Goal: Revised 11/04/25. Target Date: 02/02/26. The resident will be able to communicate basic needs on a daily basis through next review. Interventions: Discussed concerns about confusion, disease process, Nursing Home placement with resident and family. Communicate with resident and family regarding resident's capabilities and needs. Administer medications as ordered. Monitoring document side effects and effectiveness.-Care Plan revised on 04/02/25. The resident has potential to be verbally aggressive r/t Dementia. Goal: Revised: 11/04/25. Target Date: 02/02/26. The Resident will demonstrate effective coping skills by next review. Interventions: Assess resident's coping skills and support system. Assess and anticipate resident's needs: food, thirst, toilet needs, comfort level, body positioning, pain etc. Analysis of key times, places and circumstances, triggers and what deescalates behavior and comfort. Administer medications as ordered. Monitored document side effects and effectiveness.-Review of IDT - Multidisciplinary Care Conference dated 12/04/25 Type: Quarterly for Resident #2 revealed, discussed consequence of refusing treatment and concerns. Offer relevant alternatives if the Patient has refused treatment(s). Risk Factors/Prevention/Accidents/Incidents. New medication for aggressive behaviors. Found a few times with fecal matter all over the restroom or his bed. Resident refuse showers or change dirty clothes. Requested therapy for right hand weakness. -Review of IDT - Multidisciplinary Care Conference dated 11/04/25 Type: Quarterly for Resident #2 revealed, discussed consequence of refusing treatment and concerns. Offer relevant alternatives if the Patient has refused treatment(s). Risk Factors/Prevention/Accidents/Incidents. New medication for aggressive behaviors. Found a few times with fecal matter all over the restroom or his bed. Resident refuse showers or change dirty clothes. Requested therapy for right hand weakness. -Review of Physician Order Summary Dated 12/15/25 for Resident #2 revealed, Anti-Depressant SE Monitoring: Order Start Date: 12/01/25 Observe closely for significant side effects of Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift Document: 'Y' if monitored and none of the above observed. 'N' if 675831 Page 11 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitored and any of the above was observed, select chart code Other/See Nurses Notes' and progress note findings. Start Date: 12/01/25 BHV - Monitor and document any side effects related to use of Antidepressant medication. Two times a day related to Depression, unspecified Start Date: 12/01/25 Behavior Management Provider to provide psychiatric and psychosocial services evaluate and treat as warranted. Pharmacy: Start Date: 12/01/25 Benzgalantamine Gluconate Oral Tablet Delayed Release 10 MG (Benzgalantamine Gluconate) Give 1 tablet by mouth two times a day for Dementia. Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for Dementia. Start Date: 12/01/25 Hydroxyzine Pamoate Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety for 14 Days. Memantine HCl Oral Tablet 10 MG give 1 tablet by mouth two times a day for Alzheimer's disease. Start Date: 12/02/25 trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth as needed for insomnia for 14 Days at HS. Start Date: 12/01/25 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml by mouth two times a day for behaviors -Review of Physician Progress note written by Nurse Practitioner on 12/05/25 for Resident #2 revealed, Patient is being seen today s/p return to facility from GBU for an aggressive episode towards another resident in the facility. Today I witnessed patient in another resident's room noted with aggressive behavior, resident placed on 1:1 with facility staff and is pending to be sent out to GBU for reevaluation of aggression and his behavioral episode. Plan: Send to GBU for evaluation of aggressive behavior. Social Services for discharge planning. Review of contracted Behavior Health Clinical Treatment Plan dated 12/02/25 for Resident #2 revealed, Resident had cognitive ability to establish a verbal therapeutic relationship with therapist. Behavior and emotions improve in response to participation in therapy. Patient is an [AGE] year-old male who was admitted to the facility on [DATE] from the hospital. Medical records note vascular dementia. Patient referred for psych and Med management services due to anxiety, irritability, agitation, verbal physical aggression. Staff reports patient can be occasionally irritable and critical. Medical History: Alzheimer's Disease, Dementia. Resident has anxiety, depression, disorientation, emotional withdrawal. Moderate Cognitive Decline. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, Primary Treating Dx: Impulse Behavior. Secondary Treating Dx: recurrent depressive disorder. Insomnia, Delusional Disorder, Vascular Dementia, and unspecified dementia with other behavioral disturbance. Reason for Referral: Anxiety Disorder, Irritability, Anger, Verbal Aggression, Physical Aggression. Staff members were instructed to promptly inform the provider of any changes in the patient's mental status or the appearance of new or worsening symptoms, including confusion, mood alterations, anxiety, changes in appetite, or sleep issues. Oriented to person. Thought Content: Delusions. Insight: Poor. Judgement: Poor. Resident is non-verbal. Due to dementia, expectations are that the patient will most likely experience loss of function, refusal of care, behaviors (including wandering, agitation, aggression) changes in weight and further decline of cognition. Provider spoke with staff regarding the care/medication update and responses. Staff will notify provider if patient experiences changes in mental status, new or worsening symptoms of confusion, depression, anxiety, changes in appetite or sleep patterns. -Review of Behavior Health Psychiatric Subsequent assessment dated [DATE] for Resident #2 revealed, the patient voices no symptoms of depression, anxiety, changes in appetite, sleep disturbances, or psychosis but has dementia related agitation and psychosis. The patient recently was sent to GBU and returned with no change in orders. The writer made changes upon his return and is closely monitoring the changes and behaviors. Staff observed no aggression or agitation but is back at baseline in which the patient refuses showers and certain nursing care but does not get physical with redirection. Cognitive impairment. Oriented to person. Thought Content: Delusions. Labs 675831 Page 12 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed: UTI. -Review Behavioral Health Progress Note dated 10/23/25 reveal Resident #2 was oriented to person, place, and time. Disorientation: Mild. Patient's Response to Intervention: Patient was encountered in lobby and agreed to talk. Patient was cooperative and easy to engage. Patient reported feeling tired and apologized in advance if he fell asleep. Patient reported that he has noticed that he has less energy and this worries him sometimes. Patient responded well to interventions and was able to re-orient himself and identify factors affecting his mood. Plan For Next Session: Encourage patient to continue engaging in self-soothing activities. -Review of Pharmacy Consultant MMR documented for Recommendations created 12/03/2025 revealed for Resident #2, No DC Summary med list filed at time of review. Active Order reviewed. Add Q shift antianxiety side effect monitoring and targeted behavioral monitoring for Hydroxyzine. Add Q shift antipsychotic side effects monitoring and targeted behavioral monitoring for Valproic Acid. Follow-Through documented In hospital 12/05/25. -Review of Nurse's IDT notes from August 2025 December 2025 revealed, Resident #2 frequently refused showers, refused labs, propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, pushed residents out of his way as he propelled himself up and down the resident halls. He was verbally and physically aggressive with other residents and facility staff attempts were made to provide shower and personal care. Resident refused x-ray of the right hand, after he had sustained a fall 10/17/25 that caused swelling to the right hand. -Review of Elopement assessment dated [DATE] for Resident #2 revealed, Category: Not risk for elope. No history of elopement. -Review of Elopement assessment dated [DATE] for Resident #2 revealed, Category: Not risk for elope. No history of elopement. -Review SBAR Communication Form dated 12/05/25 for Resident #2 revealed, Behavioral Symptoms started on 12/05/25 and have gotten worse. During an interview on 12/11/25 at 2:40 AM with DON revealed, Resident #2 was alert and oriented to person, was able to answer simple questions, used a wheelchair for mobility, propelled his wheelchair with his feet up and down the resident halls and constantly went into other resident rooms and resisted redirection to leave the room because he thought that it was his room. She said the resident required close supervision and redirection to keep him from going into other resident rooms. She said the resident had delusions, sundown, and would push the other residents out of his way when he wheeled himself in the resident halls, refused to shower, swearing at staff when attempts were made to provide daily care, at times suspicious of others, demanding, and anxiety. She said he never attempted to leave the facility. She said the resident could not have a roommate because he preferred to be by himself, would cuss, throw water at his roommates and would ask them to leave because it was his room. She said the resident spoke some English but preferred to speak in Spanish and was able to answer questions. She said the resident had multiple medication adjustments and was taking Valproic Acid for behaviors and several medications for his dementia. She said the resident was in the 100 Hall when he was sent to emergency room on [DATE] for altered mental status and was transferred from there to the GBU on 11/20/25 and had returned to the facility on [DATE] and was placed in the 200 Hall upon re-admission because his room in the 100 hall was not available. She said that in the last incident on 12/05/25, they heard Resident #4 yelling for help and upon entering the room, found Resident #2 in her room and she was telling him to leave because it was not his room. She said Resident #4 reported he had punched her in the arm and was resisting leaving the room. She said Resident #2 was placed on 1:1 to keep him from going into other resident rooms on that day, until he was sent to the GBU. The DON said the facility staff tried to provide close supervision and re-direction to Resident #2 while they provided care to the other residents. During an interview on 12/11/25 at 2:55 AM with LVN Charge Nurse B in the 200 Hall revealed, she had been employed for a couple of months and was assigned to Resident #2. She said 675831 Page 13 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2 was re-admitted from the hospital a couple of weeks ago to the 200 Hall. She said he was occasionally oriented to person and place, and he thought he was at home. She said the resident had limited range of motion to one arm, was incontinent of bowel & bladder, was able to stand up with assistance, and needed assistance with dressing. She said he constantly propelled his wheelchair with his feet up and down the halls looking for his room. She said that on the date of the incident on 12/05/25 she and the Nurse Practitioner had heard Resident #4 yelling for help. She said that when they had entered the room, Resident #2 had one hand in a fist, and she said he had hit her, and he was pulled away. She said Resident #4 had reported she was telling Resident #2 that he was in the wrong room, and he had started cursing and had punched her in her arm. She said the Nurse Practitioner had assessed Resident #4 and had no apparent injuries. She said, I have heard from other staff say that he goes into other resident rooms. I had never seen him go into other resident rooms until the day of the incident on 12/05/25.During an interview on 12/12/25 at 3:07 PM with RN ADON C revealed that on 12/05/25 she had been notified by LVN Charge Nurse B at approximately 12:50 PM, that Resident #2 had been placed on 1:1 to prevent Resident #2 from leaving the room and going into other resident rooms until he was transferred to the GBU for evaluation of aggressive behavior. She said Resident #2 had refused to allow the staff to assess him and did not allow the staff to get close to him. She said EMS was called and he was sent to the hospital for evaluation of his aggressive behavior. She said Resident #2 was oriented to person and at times to place, propelled his wheelchair with his feet all over the facility looking for his room. She said that at times he attempted to enter other resident rooms and required close supervision and redirection from the staff. She said Resident #2 used to be in the 100 Hall and had been placed in the 200 Hall upon readmission from the hospital. She said he would frequently go to the 100 Hall looking for his room. She said Resident #2 had a history of physical aggression towards other residents and staff when care was provided. She said he had punched one of his roommates on the chest and had not caused any apparent injuries. She said on another occasion he threw water at one of his roommates because he wanted him to leave the room. She said Resident #2 had been sent to the GBU for altercations with other residents, non-compliance with medications, refusing showers and labs. She said the resident toileted with assistance and ate in the main dining room. She said he was very particular to those who sat with him at the table in dining room and would leave the dining room if he did not like the residents. She said Resident #2 had a recent incident involving Resident #4. She said Resident #2 had wheeled himself into her room and when she was telling him he was in the wrong room, he had punched her in the arm and did not cause any apparent injuries. During an interview on 12/12/25 at 3:20 PM with LVN MDS Nurse D assigned to Resident #2 revealed, he was a loner, very particular who he talked to, was occasionally oriented to person and place. She said he was also very particular to the people who sat with him in the dining room and would leave the table and go to his room if he did not like the people that sat at the table with him. She said his BIMS score was 3, which meant he was severely cognitively impaired. She said he propelled his wheelchair with his feet all over the facility looking for his room and never attempted to leave the facility. She said he would at times wheeled himself into other resident rooms, thinking that it was his room. She said he needed assistance with Activities of Daily Living and was occasionally incontinent with bowel & bladder. She said he frequently resisted personal care and would push the staff away and/or hit the staff when they attempted to provide daily care. She said he would also yell at the staff when care was provided. She said she was not aware that the wander guard had been discontinued on 11/07/25 since resident was not exhibiting wandering behaviors. During an interview on 12/12/25 at 4:01 PM with Executive Director revealed, he had issued Resident #2 a Discharge 675831 Page 14 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notice on 12/06/25 after he had been sent to the GBU, on 12/05/25 for evaluation of physical aggression. He said the reason for giving the resident a discharge notice was because he had assaulted a resident and was a threat to staff and other residents at the facility. He said Resident #2 had another incident either in January or February 2025 of this year where he kicked, punched the staff, was verbally abusive and resisted care. He said the resident also had wandering behavior and propelled his wheelchair with his feet all over the facility occasionally went into other resident rooms. He said the resident became verbally and physically aggressive when the staff attempted to redirect him. He said the resident required close supervision and redirection especially when he was around other residents. He said the resident ate his meals in the dining room and he was very particular of who sat at the table with him. He said that in the last incident on 12/05/25, Resident #2 wheeled himself into Resident #4's room, and when she had told the resident to leave because it was not his room, he had punched her in the arm. He said Resident #4 had not sustained any injuries on the day of the incident. He said that they had decided to readmit Resident #2 to the 200 Hall after he had returned from the GBU on 12/01/2025, so he could have a room to himself to prevent incidents because when they had attempted to place a roommate in his room, he would kick them or throw water at the roommates. He said that the interventions that they had attempted to keep him from being aggressive with residents and staff had been unsuccessful, and that is why the resident was issued a discharge notice because he was a threat to residents and staff. During an interview and record review on 12/15/25 at 11:44 AM, with DON revealed, she had followed up with the GBU today and was informed the Resident #2 had been discharged to a [NAME] Home. She said the Nurses IDT Notes only documented Resident #2 resisted care and did not document the resident propelled his wheelchair with his feet all over the facility and occasionally entered other resident rooms, thinking that it was his room, did not document resident required close supervision and redirection to help him find his room. She said they had started using the Wander Guard Bracelet in October 2025, she said the resident never attempted to leave the facility. However, the Wander Guard Bracelet had been discontinued due to the resident not exhibiting wandering behavior and had not been resolved in the current care plan. The DON said that she did not attend the Care Plan meetings and said that she attended care plan meetings only as needed. She said the facility had morning meetings with the nursing staff, nursing administration, and MDS Nurse to report changes in condition and behaviors exhibited by the residents. She said the MDS gathers information from the morning meetings and resident families to complete the MDS assessments. She said they had recently hired a new Social Worker. Review of the Treatment Administration Records revealed the TARs dated September 2025 through December 2025 did not document specific behaviors exhibited by Resident #2. She said the TARs did not document resident had episodes of verbal and physical aggression verbal and physical aggression towards staff when they attempted to provide care and re-direction, wandered up and down the halls looking for his room and pushed other residents out of his way, entered other resident rooms thinking it was his room and punched them and refused labs. She said the TAR did not document non-pharmatological approaches used to minimize the need for medications that addressed resident's behaviors. She said the staff had been trained in Dementia Care and Behavior Management but could not recall the dates. The state surveyor requested copies of in-service training on Dementia and Behavior Management and were not provided prior to exit. During an interview and record review on 12/15/25 at 12:30 PM, with LVN MDS Nurse D stated, they had morning meetings with the nurses and CNAs to report changes in condition, behaviors, changes in skin integrity. She said the staff had been trained to document behaviors in the Nurse's progress notes, CNA documentation sheets in the electronic clinical record. She said she was not aware if the nurses documented 675831 Page 15 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behaviors exhibited the resident and/or non-pharmacological interventions in the TARs. She said the care plan needed to be revised by the IDT after each comprehensive and quarterly MDS assessment. She did not know how changes to care plan were communicated to the staff. She said the facility did not have any documentation in the IDT notes of how often the IDT discussed resident behaviors and effect of care plan interventions. She said she had not changed the revision date on the care plan for the Risk for elopement/wandering since 4/21/25 and the interventions did not reflect the resident required close supervision and redirection to keep him from entering other resident rooms and prevent recurrence of physical aggression towards other residents. She confirmed the care plan did not document non-pharmacological interventions. She said the care plan did not address that he wheeled himself in his wheelchair up and down the halls and pushed residents out of his way. She said the facility did not have any documentation in the Care Plan dated 12/05/25 of resident triggers for physical aggression, of when and who monitored and identified triggers to de-escalate physical aggression towards other residents and staff. She confirmed the care plan interventions did not document non-pharmacological interventions to prevent physical aggression towards staff and other residents. Review of the care plan that addressed Resident #2 had mood problem r/t anxiety and agitation was last revised on 06/19/25 and did not document the resident preferred to be by himself in his room and did not like to interact with resident or staff due to easily becoming anxious and agitated. The care plan interventions did not document non-pharmacological interventions to prevent anxiety and agitation or what type of activities were provided to the resident. Review of the care plan that addressed Resident #2 was on antidepressant medication was last revised on 06/19/25. She confirmed the care plan interventions did n 675831 Page 16 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for 1 (Resident #2) of 4 residents reviewed for unnecessary medications. The facility failed to ensure Resident #2 had behavior monitoring documentation on the Treatment Administration for his prescribed Valproic Acid (an antipsychotic medication), Hydroxyzine (an antianxiety/anticholinergic medication used to treat anxiety) and Trazodone HCL (used to treat insomnia). This failure could put residents at risk of harm from adverse reactions or harmful side effects. Findings included:Closed Record review of Resident #2's admission Record revealed Original admission Date 02/16/2023 and re-admission Date 02/10/25. -Review of Hospital paperwork from Geriatric Behavioral Unit dated 12/05/25 for Resident #2 revealed, admission date 12/05/25 and discharge date [DATE]. History & Physical dated 12/05/25 revealed [AGE] year-old male transferred to Geriatric Behavioral Units from the ER, brought in via EMS, from nursing home for violent behavior and GBU evaluation. Reason for admission: danger to others, danger deterioration. History and Present Illness: According to ED notes: He was recently discharged on 12/01/25 after being admitted on [DATE] for similar reasons of aggression with staff and residents at the nursing facility. This is his 3rd admission this year, the first one in February of this year. Patient was confused, does not acknowledge behaviors that brought him here. Denies mood swings, hallucinations. The patient is unable to answer questions. Review of systems: no anxiety, no depression. Summary Statement and Safety Plan: Due to these chronic acute, protective factors, I do find this individual to be at a high risk of hurting themselves or others. Will remain in structured environment. On-going psychiatric assessment and close monitoring. Maintain inpatient care to ensure patient safety and stabilization. Estimated length of stay: 5 to 10 days. Record review of Resident #2's History & Physical dated 04/03/25 revealed [AGE] year-old male with past medical history of vascular dementia with mood disturbance (A condition where brain damage from poor blood flow causes issues with thinking and memory, along with significant emotional changes like depression, anxiety and extreme mood swings), recurrent depressive disorder (Repeated episodes of feeling deeply sad, lost interest in things, have no energy and experience other symptoms like sleep, appetite changes, and might have periods of normal moments in between the episodes before the next depressive episode comes back), generalized anxiety disorder (constantly feel anxious or on edge about everyday things. Even when there's little reason to and it's hard to turn now or control, leading to physical symptoms like muscle tension, fatigue and trouble sleeping, making daily life feel overwhelming), and impulse disorder (A struggle to stop one's self from doing things, you shouldn't, leading to sudden actions like anger outburst, stealing or binge eating, even when they cause problems to the individual or others). History of falls, status post intertrochanteric fracture of left femur (A break in the upper part of the thigh bone, right where it connects to the hip).Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed BIMS Score 3 (severe cognitive impairment), functional limitation in range of motion to upper and lower extremities, Mobility device wheelchair; requires substantial/maximal assistance with toileting hygiene, lower body dressing and putting on/taking off footwear; dependent with showers; partial/moderate assistance with personal hygiene. Set up assistance with sit to lying, sit to stand, chair/bed transfer, and tub/shower transfer and once seated in wheelchair, the ability to wheel at least 150 feet in a corridor or similar space. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), anxiety, depression, vascular dementia with mood disturbance and recurrent depressive disorder. High-Risk Drug Use - antidepressant, and anticonvulsant. Record review of Resident #2's Residents Affected - Few 675831 Page 17 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Care Plan revealed: -Care Plan revised on 12/05/25 reflected Resident #2 has potential to be physically aggressive, related to dementia and poor impulse control. Interventions: In service direct care staff on residence behaviors and how to detect escalation. Analyzed times of day, places, circumstances, triggers and what the escalates behavior and document. Administer medications and labs as ordered. Monitor for side effects and effectiveness and notify physician of effectiveness. Assess and address for contributing sensory triggers as they occur. The residence triggers for physical aggression are to be monitored and identified so they can be used to deescalate the situation. When the resident becomes agitated, intervene before agitation escalates.-Review of Physician Order Summary Dated 12/15/25 for Resident #2 revealed, Anti-Depressant SE Monitoring: Order Start Date: 12/01/25 Observe closely for significant side effects of Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings. Start Date: 12/01/25 BHV - Monitor and document any side effects related to use of Antidepressant medication. Two times a day related to Depression, unspecified Start Date: 12/01/25 Behavior Management Provider to provide psychiatric and psychosocial services evaluate and treat as warranted. Start Date: 12/01/25 Hydroxyzine Pamoate Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety for 14 Days. Start Date: 12/02/25 Trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 1 tablet by mouth as needed for insomnia for 14 Days at HS. Start Date: 12/01/25 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 10 ml by mouth two times a day for behaviors. -Review of Pharmacy Consultant MMR documented for Recommendations created 12/03/2025 revealed for Resident #2, No DC Summary med list filed at time of review. Active Order reviewed. Add Q shift antianxiety side effect monitoring and targeted behavioral monitoring for Hydroxyzine. Add Q shift antipsychotic side effects monitoring and targeted behavioral monitoring for Valproic Acid. Follow-Through documented In hospital 12/05/25. -Review of Resident #2's Medication Record and TAR Record dated December 2025 revealed, he had received Hydroxyzine, Trazodone HCl, and Valproic Acid Oral Solution as ordered. The TAR reflected the resident was monitored for side effects of antidepressant every shift and documented no side effects were observed. The TAR documented BHV - Monitoring and document any side effects related to use of antidepressant. The TAR did not document resident's targeted behaviors and did not document non-pharmacological interventions. The TAR only documented the nurse's initials. The TAR did not document to monitor targeted behavioral monitoring Q shift for Hydroxyzine and Valproic Acid and did not document non-pharmacological interventions.During an interview and record review on 12/16/25 at 1:45 PM, with DON revealed, TARs dated September - December 2025 did not document specific behaviors exhibited by Resident #2 such as verbal/physical aggression, refusal of care, refusal of labs and propelling his wheelchair up and down the halls and into other resident rooms. She said the TAR dated December 2025, only documented Side Effect Monitoring for use of anti-depressant, antipsychotic and antianxiety medications and did not document monitoring of targeted behavior and/ non-pharmaceutical interventions. Review of the facility's Policy & Procedure on use of Psychotropic Medication Use dated July 2022 revealed, Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation. Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications. Anti-psychotics., Anti-depressants., Anti-anxiety medications 675831 Page 18 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Hypnotics. Psychotropic medication management includes: Indication for use; dose (including duplicate therapy); duration, adequate monitoring for efficacy and adverse consequences; and preventing, identifying and responding to adverse consequences. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Nonpharmacological approaches are used (unless Contraindicated) To minimize the need for medications, Permit. The lowest possible dose and allow for discontinuation of medications when possible. Residents on psychotropic medications received gradual dose reductions, unless medically contraindicated, in an effort to discontinue these medications. Resident Evaluations: Situations which may prompt an evaluation or re-evaluation for the resident include: admission or re-admission; A clinically significant change in conditions/status; a new, persistent, or recurrent clinically significant symptom or problem; a worsening of an existing problem or condition; a new medication order or renewal of orders; or an irregularity identified in the pharmacist's medication regimen review. 675831 Page 19 of 20 675831 12/16/2025 Edgemere Estates 10880 Edgemere Blvd El Paso, TX 79935

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interviews and record review, the facility failed to ensure 4 of 11(LVN E, CNA L, CNA G, and Activities Director) employees whose in-service records were reviewed had not received the required minimum 1-hour annual in-service training for Dementia and Behavior Management. The facility failed to keep copies of documentation of the required annual Dementia and Behavior Management training for LVN E, CNA L, CNA G, and Activities Director before the change of ownership was completed on December 04, 2025. This failure placed residents at risk for unmet needs due to untrained staff. Findings included: During an interview and Record Review on 12/16/25 at 4:42 PM with HR Payroll Coordinator revealed they had a change of ownership on December 04, 2025, and she no longer had access to training records from the previous company to show Dementia/Behavior/Communication training was completed on an annual basis according to facility policies for the following employees. -LVN Charge Nurse E was hired on 05/18/25. Documentation revealed Dementia/Behavior/Communication training was completed on 04/07/25. No previous training records were available to review due to change of ownership. -CNA L was hired on 10/27/23. Documentation revealed Dementia/Behavior/Communication training was completed on 09/25/25. No previous training records were available to review due to change of ownership. -CNA G was hired on 05/31/24. Documentation revealed Dementia/Behavior/Communication training was completed on 08/05/25. -Activities Director was hired on 09/25/19. Documentation revealed Dementia/Behavior/Communication training was completed on 08/05/25. No previous training records were available to review due to change of ownership. -During an interview on 12/15/25 at 4:00 PM, revealed he was trained this year but could not recall what date he had completed the computer training on Dementia/Behavior/Communication. - During an interview on 12/16/25 at 1:30 PM revealed, she did not recall if she had received training on Dementia/Behavior/Communication. -During an interview on 12/16/25 at 2:27 PM with the Executive Director revealed they had a change of ownership on 12/04/25. He said, So everyone was considered to be a new hire. He said they had not made copies of training records for the facility staff prior to the change of ownership and did not have documentation of the last annual training on Dementia and Behavior Management for some of the staff. He said, Like I said all the staff are considered to be new hires due to change in ownership and we are in the process of completing the annual training on Dementia and Behavioral Management. Review of facility's Policy and Procedure on Dementia Care implemented 11/2017 revealed, Policy: It is a policy of this facility to provide the appropriate treatment and services to every resident who display signs of or is diagnosed with dementia to meet his or her highest practical, physical, mental and psychological well-being. Explanation and Compliance Guidelines. The care plan interventions will be related to each residence individual symptomology and rate of dementia (or related diseases) progression with end result being noted improvement or maintain of the expected stable rate were decline associated with dementia and dementia like illnesses. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. If needed, the environment will be modified to accommodate individual resident care needs. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. All staff will be trained in dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies, and skill sets to ensure resident's safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. 675831 Page 20 of 20