Health inspection·August 6, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Family notified for Resident # 2 at 2020 (8:20 pm) and received a return call from Resident # 1family at 2105 (9:05 pm). Skin tear cleansed with w/c and wrapped with kerlix to stop bleeding. Record review of a nursing progress note dated 08/02/2024 revealed SW met with Resident # 1 in her room. Resident # 1 in her bed appeared to be resting. SW asked Resident # 1 how she was doing this morning and she replied ok. SW asked Resident # 1 if she feels safe and she replied yes. SW asked Resident # 1 if she feels afraid and resident replied no. SW asked resident what happened to cause altercation between her and her roommate. Resident # 1 replied that her roommate just kept yelling at her that she was lazy and couldn't do for herself. Resident # 1 said she likes to take up for herself and when she did her roommate kicked her in the leg. SW asked Resident # 1 if she slapped her roommate and Resident # 1 replied no. Resident # 1 expressed, she is glad she moved to her new room. SW has assessed Resident #1 for fearfulness or distress related to this occurrence. Currently Resident #1 is not showing any signs or fearfulness or distress and feels safe. Record review of Resident # 2's admission face sheet dated 08/06/2024, revealed Resident # 2 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of personal history of transient ischemic attack (A brief interruption of blood flow to the brain that causes stroke like symptoms) and cerebral infarction (An ischemic stroke which occurs as a result of disrupted blood flow to the brain), permanent atrial fibrillation (An irregular often rapid heart rate that commonly causes poor blood flow), hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), osteoarthritis (A type of arthritis that occurs when flexible tissue at the ends of bones wear down), chronic kidney disease stage 3 (When the kidneys have moderate damage and are less able to filter waste and fluid from the blood), dementia with other behavioral disturbance (A group of thinking and social symptoms that interferes with daily functioning). Record review of the MDS assessment dated [DATE] revealed Resident # 2 had clear speech and was understood by staff. The MDS revealed Resident # 2 usually understands others. The MDS revealed Resident # 2 had a BIMS score of 8, which indicated moderate cognitive impairment. The MDS reflected Resident # 2 had no behaviors or refusal of care. Record review of the care plan, initiated on 12/12/2023 revealed Resident # 2 has impaired cognitive function/dementia or impaired thought processes. Interventions included monitor/document/report to MD any changes in cognitive function specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Record review of care plan, initiated on 05/20/2024 revealed Resident #2 has potential to demonstrate physical behaviors and has potential for injury related to will strike out at staff when attempting to provide care. Resident # 2 goal stated the resident will not harm self or others thru review date. Interventions included if resident has physical behaviors towards another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Record review of the nursing progress notes dated 08/01/2024 at 20:51 (8:51 pm) revealed LVN A documented: As I walked into room [ROOM NUMBER], I heard Resident # 2 tell Resident # 1 you are a lazy b Resident # 1 responded she doesn't bother anybody, and that Resident # 2 had kicked her. Upon completing a physical assessment of both residents Resident # 1 had a skin tear approx. 5 cm by 1 cm to her lower left leg. No injuries noted on Resident # 2. Residents were immediately separated. Family notified for Resident # 2 at 2020 and received a return call from Resident # 1family at 2105. Resident # 2 said Resident # 1 is a lazy b . that she needed to get up and that she doesn't try hard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 enough. DON and NP notified of event. Level of Harm - Minimal harm or potential for actual harm Record review of the nursing progress notes dated 08/02/2024 at 9:20 am revealed SW met with Resident # 2 in SW office to assess how Resident # 2 is doing this morning after the altercation with her roommate last night. SW asked Resident # 2 if she felt safe and Resident # 2 replied yes. SW asked Resident # 2 if they were afraid, and Resident # 2 replied no. SW asked Resident # 2 what happened. Resident # 2 stated they were in bed last night and her roommate Resident # 1 kept yelling for an aide to help her to the bathroom. Resident # 2 said she put her call light on to try and help her roommate but Resident # 1 kept keeping Resident # 2 up and Resident # 2 became agitated. Resident # 2 then said Resident # 1 slapped her. SW asked Resident # 2 how Resident # 1slapped her if they were in bed. Resident # 2 said that's right we were in our wheelchairs and then Resident # 1 slapped me and I then kicked her in the leg, but it was already hurt. SW asked Resident # 2 why she kicked Resident # 1 and Resident # 2 responded I was taught to defend myself and if you grew up the way I did with a bunch of siblings you would too. Resident # 2 then expressed she can take herself to the bathroom and do things for herself and that her roommate Resident # 1 is always needing help and can't do for herself and that bothers her. SW explained that not everyone is the same and some need the help of staff and those that don't are very lucky. SW discussed with Resident # 2 that her roommate Resident # 1 has moved to another room and Resident # 2 replied that's a good thing and might be for the best. SW educated Resident # 2 about not physically using her arms or legs to hurt another resident, even if she is upset, and that going forward she should notify staff using her call light to prevent any other altercations with other residents. SW completed a SLUMS with Resident # 2 and she scored a 9 which, a score of 1-20 indicates dementia. SW has assessed Resident # 2 for fearfulness or distress related to the occurrence and at this time Resident # 2 appears safe, calm, and unafraid. SW did discover the root cause of Resident # 2 agitation. Resident # 2 feels that at her age you should be able to do for yourself and not ask for help from others. SW feels that Resident # 2 lashed out at her roommate Resident # 1 because she needs assistance with ADL's and uses her call light to get that assistance. Residents Affected - Few Record review of the nursing progress notes dated 08/02/2024 at 10:50 am SW notified RP of Resident # 2 that due to the altercation with Resident # 1 last night the SW recommends a referral to psych services and RP agreed to psych services. Record review of the nursing progress notes dated 08/02/2024 at 12:38 pm revealed SW sent referral for psych services for urgent telehealth visit. Record review of the nursing progress notes dated 08/02/2024 at 13:14 (1:14 pm) revealed SW contacted Resident # 2 RP about psych not knowing Resident # 2 prior and recommends that Resident # 2 be sent out to a psych hospital for evaluation. SW explained to RP at this time Resident # 2 is not showing signs of frustration or aggression, Resident # 1 has been moved, neither resident feels afraid nor distressed at this time. RP said he feels sending Resident # 2 to the psych hospital would be extreme and does not want Resident # 2 sent out. SW agreed and let RP know that the SW would continue to monitor the situation. Record review of the nursing progress notes dated 08/05/2024 at 11:04 am revealed SW followed up with Resident # 2 this morning. SW asked Resident # 2 how she was doing, and Resident # 2 said she was doing good. No aggression or frustration noted. Resident is adjusting to having a new roommate and SW encouraged Resident # 2 that it will take time to get to know each other. SW asked Resident # 2 if she told her new roommate that she didn't belong in the room and Resident # 2 responded no. Resident # 2 then said her new roommate stays in bed all day and she does not. SW reminded Resident # 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 that they share a room and if her roommate wants to stay in bed all day then she can. Level of Harm - Minimal harm or potential for actual harm Record review of the nursing progress notes dated 08/06/2024 15:27 (3:27 pm) revealed it was reported to SW that Resident # 2 was being verbally aggressive to her new roommate. To minimize any further behavior Resident # 2 RP was contacted and agreed to Resident # 2 moving to a room without a roommate. Residents Affected - Few Record review of the nursing progress notes dated 08/06/2024 16:18 (4:18 pm) revealed SW noted Resident # 2 will be seen on 08/08/2024 at 11:00 am for psych evaluation via telehealth. Record review of email dated 8/2/24 at 12:30 pm SW sent to psych facility for referral for Resident # 2 for evaluation. Observation/Interview on 8/6/24 at 1:15 pm with Resident # 1 revealed Resident # 1 said they feel safe, and staff take good care of them. Resident # 1 said they were happy they moved rooms and had no concerns with their new roommate. Resident # 1 said her prior roommate Resident # 2 was upset with her and had injured her legs. Resident # 1 said she was not sure why Resident # 2 was upset with her and that she was not afraid of her as she did not see her anymore. Resident # 1 said her prior roommate got upset with her anytime she called for help. Resident # 1 said she only called for help when she needed it. Resident # 1said her leg was bleeding and hurt after her roommate kicked her. Resident # 1would not answer as to how the incident made her feel. Resident # 1 said she did not want to get anybody in trouble and since she moved rooms it was not a problem now. Interview on 8/6/24 at 1:28 pm with Resident # 2 revealed Resident # 2 said they feel safe, and that staff do the best they can to assist. Resident # 2 could not recall the altercation that had happened with Resident # 1. Resident # 2 said they do not use their call light as they do for themselves. Interview on 8/6/24 at 4:04 pm with the SW revealed SW said she had met with each resident after the altercation occurred. The SW said the interventions that had been put in place was to separate the residents immediately, have Resident # 1 move rooms, and contact psych services for an evaluation. The SW said after the allegation of Resident # 2 verbally abusing her current roommate the intervention of moving Resident # 2 to a room without a roommate and continued monitoring until the psych evaluation could be completed and the recommendations received from psych services. The SW said this intervention had been put into place for the safety of the other residents and the resident herself. Interview on 8/6/24 at 6:19 pm with the AD revealed the AD said abuse can be mental, physical, or sexual. The AD said abuse was any willful or intentional harm of someone. The AD said yes abuse can occur between residents. The AD said negative outcomes of abuse can be physical harm, being fearful, scared, intimidated, uncomfortable in their own home. The AD said the procedure for a resident-to-resident altercation was to immediately separate the residents, perform a physical and emotional assessment of each resident, notify MD and RP, establish what interventions are needed for both parties involved, complete the self-report, train, and educate staff, monitor for behaviors, and review during the facility QAPI meeting. AD was asked if Resident # 2 had hurt any other residents in the past and AD responded no they had not. AD said they felt like the proper interventions had been put in place after the incident with Resident #1 and Resident #2. AD said the facility investigation of this incident confirmed this incident occurred. AD would not directly answer if this incident was abuse. AD said staff have received in-service/training on resident-to-resident behaviors, abuse/neglect/misappropriation, change of condition, answering call lights, Q-2-hour resident rounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of in-services with topics of: Resident to resident behavior dated 8/1/24 revealed 25 staff in attendance, Abuse/Neglect/Misappropriation 8/1/24 with 28 staff in attendance, Q-2-hour resident rounds 7/31/24 with 12 staff in attendance, answering call lights 7/31/24 with 14 staff in attendance, Change of condition 7/29/24 with 28 staff in attendance, Record review of the facility investigation for intake 522101 included resident safe surveys conducted, staff questionnaire about resident-to-resident monitoring for behaviors, progress notes, and residents head to toe assessments completed. Record review of the Abuse policy with a revision date 08/2019 revealed under heading policy: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form and to report in accordance with the law any incidents/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Under heading procedure 6. Protection c. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the home's primary concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 5 of 5