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 (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: 455522 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 455522 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Temple West 1700 Marlandwood Rd Temple, TX 76502 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)