Health inspection·November 20, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's right to be free from abuse for 1 of 7 residents (Resident #2) reviewed for abuse in that:The facility failed to ensure Resident #2 was free from abuse by Resident #1 on 07/25/2025 when Resident #1 hit Resident #2 in the face. This failure could place residents at risk of abuse and psychosocial harm. Findings included:Resident #1Record review of Resident #1's admission record, dated 11/20/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included unspecified dementia (loss of memory), schizoaffective disorder, bipolar type (a mental illness that combines symptoms of schizophrenia [chronic mental disorder affecting thoughts, perceptions, emotions, and social interactions] and a mood disorder but does not meet the criteria for either alone), and personal history of traumatic brain injury (damage to the brain caused by a head injury). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating intact cognition. Further review of the MDS revealed no behavior exhibited for physical behavioral symptoms directed towards others; the resident's verbal behavior towards others and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) were coded 2 (Behavior of this type occurred 4 to 6days, but less than daily).Record review of Resident #1's care plan revealed the following:- Resident #1 requires psychotropic medications and antiseizure for Behavior management DX Schizoaffective and Bipolar and History of Traumatic Brain Injury. Date initiated 06/20/2025. - Resident #1 has potential to demonstrate physical behaviors hit another resident r/t Anger, Dementia. Date initiated 07/28/2025.Record review of Resident #1's nursing note, dated 07/25/2025 at 5:39 pm, revealed Received a phone call from [Name], NP with Dr. [name], requesting clarification regarding a recent incident involving the resident. Explained that this nurse was informed by staff that the resident was witnessed by dietary personnel physically assaulting another resident. According to the report, the resident appeared upset that the other resident was looking at him while he ate. He was initially seated one table away, then rolled over in his wheelchair and punched the other resident on the right side of the face without any verbal exchange. [Name], NP gave verbal orders to initiate a 1:1 sitter with 15-minute safety checks, to obtain an X-ray of the face if the resident complains of pain or discomfort, and to proceed with referral and transfer to an inpatient psychiatric facility as needed. Informed NP that [Facility Name] may have a potential bed available, and nursing staff will send documentation for possible admission. NP verbalized understanding and agreement. Also updated NP that the facility has been actively working on discharge placement, but efforts have been complicated by the resident's ongoing wound care needs. The assigned nurse was instructed to notify the resident's family regarding the incident and plan of care.Record review of Resident Page 1 of 4 675961 675961 11/20/2025 Regency Village 409 W Green Webster, TX 77598

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1's nursing note, dated 07/25/2025 at 7:45 pm, revealed Resident physically assaulted another resident. He stated the other resident was taking food from a female in the dining room and he hit him. The two were immediately separated and all parties were notified of the assault.Record review of Resident #1's nursing note, dated 07/25/2025 at 9:40 pm, revealed pt. was relocated to the 500 hall currently has a 1:1 sitter. pt calm with no outward s/s of aggression or agitation.Record review of Resident #1's nursing note, dated 07/26/2025 at 8:16 am, revealed Patient continues to remains on 1:1 observation with dedicated staff per physician order and safety protocol. Throughout the shift, the patient has presented as calm, cooperative, and emotionally stable. No episodes of verbal or physical aggression have been observed or reported to writer. Patient is engaging appropriately with staff and peers and displays a mood congruent with affect. Notably, the patient has exhibited intermittent forgetfulness, including repeated questioning about whether pain medication was administered. Writer provided reassurance and clarification, and patient was redirected without resistance. No signs of distress, confusion, or agitation were noted following redirection.Record review of Resident #1's telehealth progress note, dated 07/28/2025 revealed .Other Symptoms: Highly irritable. Physical aggression towards others. Verbal aggression. [Name], LVN called to reported the patient is becoming verbally and physically aggressive. The nurse reported the patient assaulted another resident. No injuries reported. The facility attempted to send out the patient to an inpatient psych hospital but he was denied due to his wounds. The patient is currently on 1:1 observation with checks every 15 minutes. Plan: Continue 1 on 1 monitoring. Increase Depakote DR 1250mg QAM &QPM Continue 1000mg noon dose. Obtain CBC/VPA on 1 week send me results.Record review of Resident #1's nursing note, dated 07/28/2025 at 3:16 pm, revealed Tele health visit with [name] NP took place with resident. Resident was overheard stating that he did punch another resident in the face but it was self defense and provoked by the other resident. (Witness statement states otherwise) Resident was advised to seek assistance from staff members in the future, and not to take matters into his own hands. After visit was completed, [name] NP called back with new orders to increase Depakote, continue 1:1. (Will re evaluate on Wednesday) And labs in one week.Record review of Resident #1's psychiatric progress note, dated 07/30/2025 revealed Patient reveals: ‘I'm all right'. Meeting with staff reveals: Meeting with facility staff indicates the patient has: Normal appetite. No anxiety and no irritability, and no hostility toward peer(s). No hostility toward caregivers. No depression and no sleep complaints. Energy level is normal. No physical aggression. No paranoid ideations and not resisting assistance with activities of daily living. No social isolation. Not refusing treatment. No verbal aggression. The patient verbalized to me if he becomes irritable and wants to become verbally or physically aggressive with anyone he would walk away and notify staff.Plan: Discontinue 1 on 1 observation at this time.Resident #2Record review of Resident #2's admission record, dated 11/20/2025, revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included malnutrition (not getting the right amount of nutrients), myocardial infarction (heart attack), Type 2 Diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), unspecified dementia (loss of memory), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate cognitive impairment. Further review of the MDS revealed no behaviors exhibited for the following: physical behavioral symptoms directed towards others; the resident's verbal behavior towards others and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal 675961 Page 2 of 4 675961 11/20/2025 Regency Village 409 W Green Webster, TX 77598

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few symptoms like screaming, disruptive sounds).Record review of Resident #2's care plan revealed the following: - The resident has a behavior problem (hitting, kicking, scratching staff) r/t dementia. I also smear BM on privacy curtain, date initiated 09/17/2024. - The resident has a psychosocial well-being problem actual r/t other resident hitting him, date initiated 07/28/2025. - Behavior: Verbal Threats dated initiated 08/07/2025. - The resident has a behavior problem r/t can be aggressive towards other residents and staff, date initiated 10/21/2025. Record review of Resident #2's nursing notes, dated 07/25/2025 7:41 pm, revealed Resident was physically attacked while in the dining room. He was punched in the face while sitting at a table. He and the aggressor were immediately separated. He was assessed and had no physical bruising and denied having pain. Resident stated he was fine. He returned to his room and got into his bed. All parties notified of the incident.Record review of Resident #2's nursing notes, dated 07/29/2025 2:16 am, revealed facial xray 2V results: No evidence of facial bone dislocation or fracture.Record review of Resident #2's skin assessment, dated 07/25/2025, revealed no changes to skin. Record review of Resident #2's post incident assessments, dated 07/25/2025 and 07/26/2025, revealed Resident #2 did not show any signs of emotional distress or changes to behavior. Record review of the facility's investigation report revealed On 7/25/2025 at 5:09, Resident stated that his roommate was trying to take food from a female resident in the dining room. Resident punched other resident in the rt. side of face without any words exchanged. Nurse assessed both residents, no injuries, no adverse effects. Witnessed by [Name], Cook. Emotional distress Q shift X 3 days, skin assessment, resident safety interviews initiated .Record review of the undated statement, written by [NAME] A revealed I [name] Dietary Cook, witnessed [Resident #1] punch [Resident #2] in the right side of face. [Resident #1] was upset because [Resident #2] was looking at him eat. [Resident #1] was 1 table away, he rolled over and punched him with no words.Observation on 11/19/2025 at 3:13 pm, Resident #1 was well groomed and dressed, sitting up in his w/c, appeared asleep. Interview was unsuccessful as Resident #1 did not wake up and answer surveyor questions. Observation on 11/19/2025 at 3:29 pm revealed Resident #2 was lying in bed, awake. Interview was unsuccessful as Resident #2 did not answer surveyor questions. Interview on 11/20/2025 at 9:55 am, the DON stated she did part of the investigation but did not witness this incident. She stated psych followed Resident #1, and staff managed his behaviors by redirection. The DON stated Resident #1 had anxiety, and some interventions included scheduling a day and time for when he could purchase items, scheduled days he received his money, talk with her or another staff member when feeling anxious, and monitoring Resident #1 in the dining room since most of his incidents happened in the dining area. The DON stated staff were in serviced on Abuse and Neglect by herself, the Administrator or the ADON and staff were taught to de-escalate resident behaviors and separate residents if an altercation occurred.Interview on 11/20/2025 at 2:02 pm with Resident #2 was unsuccessful, Resident #2 did not answer surveyor questions. Observation and interview on 11/20/2025 at 2:05 pm, revealed Resident #1 in his room, lying in bed. Resident #1 stated he had issues with his memory. When asked about the incident, Resident #1 stated he was in the dining room, and needed to get something so he went around to the line. He said he then told Resident #2 he was going to kick his ass because Resident #2 was sitting and eating his food. Resident #1 denied punching Resident #2 and said he knew better than to hit him because he was in a w/c, and elderly. Resident #1 stated if someone were to get ahold of him first, he would hit them. Interview on 11/20/2025 at 5:34 pm, the DON stated there was potential for residents who acted out to get hurt or potential for them to hurt other residents. She stated they tried to prevent instances of resident-to-resident abuse by providing a safe environment, monitoring any behaviors, and managing medications. The DON stated nurses were responsible for monitoring behaviors and 675961 Page 3 of 4 675961 11/20/2025 Regency Village 409 W Green Webster, TX 77598

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meds, and to notify the MD with changes. She said the IDT team was responsible for coordinating with psych services, and discussing any changes. Interview on 11/20/2025 at 5:51 pm, the Administrator stated there was a risk to everybody and the problem was when they tried to send Resident #1 out for psych, he was denied due to his wound and there were not a lot of options. He stated Resident #1 was being seen by psych in house, but there were not other long term care psych facilities nearby. He stated staff monitor the residents with behaviors and they did the best they could. He said they could not have all residents on 1:1, so they would identify the residents who needed more monitoring for staff to keep their eyes on them. Phone interview on 11/20/2025 at 6:09 pm, [NAME] A stated Resident #1 punched Resident #2 in the face, and Resident #2's face was red. He said Resident #1 was aggressive at the time of the incident. [NAME] A stated he did not see Resident #2 eat Resident #1's food during the incident. Record review of facility policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2021, revealed All types of resident abuse, neglect, exploitation or misappropriation of resident property are strictly prohibited. 675961 Page 4 of 4