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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 455489 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 455489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Jeffrey Place 820 Jeffrey Dr Waco, TX 76710 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)