Health inspection·April 15, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately to the State Survey Agency (HHSC), but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, for 1 of 4 residents (Resident #1) reviewed for abuse. The facility did not report to the State Survey Agency (HHSC) an incident of alleged abuse/neglect for Resident #1. This failure could place residents at risk for harm to include physical abuse, a diminished quality of life, and psychosocial harm. The findings included: Record review of Resident #1 's face sheet, dated 4/15/2025 reflected a [AGE] year-old female resident re-admitted to the facility on [DATE] with diagnoses that included: Acute Respiratory Failure with Hypercapnia (occurs when the lungs fail to adequately remove carbon dioxide from the blood), Congestive Heart Failure (a condition where the heart can't pump enough blood to meet the body's needs), and Chronic Obstructive Pulmonary Disease (a condition caused by damage to the airways or other parts of the lung). The resident is her own responsible party. Record review of Resident#1's quarterly MDS, dated [DATE], revealed: the resident's BIMS score was fifteen (intact cognition). During an interview on 4/15/2025 at 8:45 AM the ADM stated Resident #1 came to him seven days after the alleged incident on 2/26/2025. Resident #1 stated a male CNA, who previously worked for the facility and was visiting his girlfriend who worked there, came into her room around 2:00 AM and made a suggestive, vulgar comment to her. Resident #1 stated the male did not touch her. The ADM investigated the allegation, Resident #1 was assessed, and was deemed inconclusive. The ADM said he would normally report this type of situation and I did not report the allegation because Resident #1 said she did not want it reported. Later we decided to report it because we felt like she was playing games with us, as she shared the allegation with other staff and residents. During an interview on 4/15/2025 at 9:33 AM, Resident #1 stated, I do not feel unsafe here. I did not want to stir up anything. I did not want my family to know because they would have come in and tried to take things over. I said I did not want the state, or the police called. Resident #1 stated a Page 1 of 4 455522 455522 04/15/2025 Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few male, who previously worked for the facility and was visiting his girlfriend who worked at the facility, came into her room around 2:00 AM and made a suggestive, vulgar comment to her. Resident #1 stated the male did not touch her. During a telephone interview on 4/15/2025 at 12:42 PM, the SW stated, Resident #1 reported the allegation to me after she reported to the ADM. She said she did not want it reported and I informed her I had to report it. I spoke with the ADM and told him we should report the allegation , he agreed. She said she was unsure why the ADM did not report it. Resident #1 stated a male, who previously worked for the facility and was visiting his girlfriend who worked at the facility, came into her room around 2:00 AM and made a suggestive, vulgar comment to her. Resident #1 stated the male did not touch her. Resident #1 stated she did not feel unsafe. During an interview on 4/15/2025 at 3:30 PM the ADM stated he did not report the allegation because he was honoring Resident #1's request to not have it reported. The ADM is the Abuse Coordinator and received the initial allegation. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating (MED-PASS, Inc. Revised September 20222) reflected the following: Reporting Allegations to the Administrator and Authorities 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and 455522 Page 2 of 4 455522 04/15/2025 Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502

F 0609 g. Level of Harm - Minimal harm or potential for actual harm The facility medical director. 3. Residents Affected - Few Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. 455522 Page 3 of 4 455522 04/15/2025 Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502

F 0609 Level of Harm - Minimal harm or potential for actual harm Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Residents Affected - Few 455522 Page 4 of 4