Health inspection·May 7, 2024

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 Interviews and record reviews, the facility failed to ensure residents were free from verbal abuse for one of 6 residents reviewed for abuse. The facility failed to prevent verbal abuse for Resident # 1 as self-reported by CNA A when she responded in the smoking area to Resident # 1 one yelling at her and calling her a Bitch, by repeating the statement to the resident. The noncompliance was identified as Pass noncompliance that began on 4/21/2024 and ended on 4/22/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse. Findings include: Review of Resident # 1's face sheet dated 5/7/2024 revealed a [AGE] year-old female admitted to the facility 8/18/2023 with diagnosis that include Unspecified mood [affective] disorder (characteristic of depressive disorder and can cause clinically significant distress or impairment in social, occupational, or other important areas) Parkinson's Disease (a disorder of the nervous system), Cognitive communication deficit. (Difficulty with thinking and how someone uses language). Review of Resident # 1 Quarterly MDS dated [DATE] revealed a BIMS score of 11 which can indicate a moderate cognitive impairment. Resident # 1 behavior and functional status revealed she had no physical or verbal behavioral symptoms or decreased in mood or social isolation, Resident is independent with all activities of daily living and is continent of bowel and bladder. Review of Resident # 1's care plan revised 4/21/2024 revealed a problem of verbally aggressive with staff when being redirected during smoke breaks if she is out of cigarettes. Approach is RP will ensure the Resident # 1 has cigarettes of her own to decrease behaviors related to not having cigarettes. Interview with 5 LVN's and 14 CNAs over all shifts on 5/7/2024 revealed staff were able to identify types of abuse, and the abuse coordinator for reporting. Interview with Resident # 1 on 5/17/2024 at 1:00 pm stated she felt safe in the facility, and she did not recall the incident or the name calling, during the interview the resident was focused on not having cigarettes that day instead of the incident. Resident stated she has not issues with the Page 1 of 4 455489 455489 05/07/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0600 aides and they are very good about answering her call light and meeting her needs. Level of Harm - Minimal harm or potential for actual harm Attempted Phone interview with CNA A 5/17/2024 at 1:30 pm no answer, voice message left asking for return call. Residents Affected - Few Interview with DON on 5/17/2024 at 1:45 pm stated her expectations are that all employee's treat the resident with respect and abuse of any kind is not tolerated. When CNA A self-reported the verbal abuse of Resident # 1 by herself, she had no choice to terminate her and classify her as a Non rehire. She stated she was not sure if a referral was made on the CNA. Interview with ADM on 5/17/2024 at 2:00 pm stated her expectations that Abuse of any type is not acceptable with policy will be enforced regardless of who reports the abuse. She stated that since the verbal abuse was confirmed by CNA A per policy with confirmed abuse she was terminated. She stated she was not sure what the policy of the company of referring the CNA A and will explore it. Review of Incident statement dated 4/21/2024 signed by the DON, revealed the following, notified at 4:47 pm by CNA A that during the smoke break Resident # 1 called her a Bitch for redirecting her behavior. CNA A reported that before she knew it, she had called Resident # 1 a Bitch in return. Review of Witness statement dated 4/21/2024 signed by CNA A revealed that she did call Resident # 1 the aforementioned word in response to the Resident's use of the word to her. She then went to the charge nurse and reported the incident. Review of Witness statement dated 4/21/2024 signed by Resident # 1 revealed that she does not recall using the word prior to CNA A using it , but did use it in reply. Record review of CNA A employee filed revealed a termination counseling dated 4/21/2024. Signed by the DON on 4/22/2024. Review of Resident # 1's medical record revealed a progress note dated 4/21/2024 signed by the NP, with an assessment of Resident # 1's behavior with no mention by the resident of the incident, just that she is out of cigarettes and that upsets her. Review of in-services on Abuse, Neglect and Exploitation dated 4/21/2024 and employee roster, revealed training was provided to staff on 4/22/2024. Review of facility policy titled Abuse, Neglect and Exploitation revised 10-2023 revealed the following the facility will provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse, neglect and exploitation and misappropriation of property. Employee training B. existing staff will receive annual education through plan ins-services and/or assigned web-based training. Training topic will include 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. The surveyor confirmed PNC had been implemented sufficiently to remove the deficiency by: Facility implementation of monitoring resident for psychosocial harm. 455489 Page 2 of 4 455489 05/07/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0600 Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC. Level of Harm - Minimal harm or potential for actual harm Facility Completion of investigation of Incident. Assessment of Resident # 1 by Nurse Practitioner on day of incident. Residents Affected - Few Completion of in-services on abuse. Termination of confirmed perpetrator. The noncompliance was identified as PNC. The facility had corrected the noncompliance before the survey began. 455489 Page 3 of 4 455489 05/07/2024 Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, for 1 of 4 medication carts review for medication storage that Medication cart # 1 was left unattended and unlocked in the hallway not facing the wall. This failure could allow resident, unsupervised access to prescription and over-the-counter medication, and can result in the resident can receive medication that had not maintained the effectiveness due to lack of temperature management or proper labeling. Finding Include: Observation on 5/7/2024 at 3:06pm revealed a medication cart in front of a resident's room, unlocked with the top drawer slightly opened and no staff member in site. Upon inspection the medication cart had medical supplies, prescription and over-the counter medications. There we 2 residents in the hallway at the time of observation. LVN A returned to the cart at 3:08 pm and secured the cart. Interview of LVN A on 5/7/2024 at 3:08 pm revealed that she was unaware she did not lock the medication cart prior going into the resident's room. She stated that another resident might have gotten something from the cart while it was unattended. Interview with DON on 5/7/2024 at 3:30 pm revealed her expectations where that when the medication cart be locked when out of sight of the employee or positioned in the open doorway of a resident's room with the drawers facing in toward the room per the policy. She stated that another resident may get something out of the cart they were not supposed to have which is a potential risk. Interview with ADM on 5/7/2024 at 345 pm revealed her expectations are that all facility policies be followed to ensure the safety of the residents. Not doing so can put the resident at potential risk. Record Review of policy Administering Medication revised April 2019 on 5/7/2024 at 3 35pm stated. 16. During administration of medications, the medication cart is kept closed and locked when out of sight the medication nurse or aide. It may be kept in the doorway of the resident's room with open drawers facing inwards and all other sides closed. 455489 Page 4 of 4