Health inspection·April 21, 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 interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 24 hours after the allegation was made to the State Survey Agency for 2 of 5 residents (Resident #1 Resident #2) reviewed for abuse. The facility failed to report within 24 hours to the State Survey Agency (HHSC - Health and Human Services Commission) that there was alleged physical abuse between Resident # 1 and Resident # 2 when staff reported to the ADM on 04/05/2025. Resident #2 pushed/hit Resident # 1 in the chest as they passed each other in the hallway on date 04/05.2025. This failure could place residents at risk for further abuse. Findings included: A record review of Resident #1's face sheet dated 04/19/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis was end stage renal disease(kidneys lose the ability to remove waste and balance fluids), essential primary hypertension(abnormal high blood pressure), and osteoarthritis(flexible tissue at the ends of bones wears down). A record review of Resident #1's Quarterly MDS assessment, dated 01/29/2025, reflected the resident had a BIMS score of 15, which indicated cognitive intact. A record review of Resident #1's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area. A record review of Resident #2's face sheet dated 04/19/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnosis was cerebral infraction(blood flow to the brain blocked), type 2 diabetes(body having trouble controlling blood sugar and using it for energy), and vascular dementia(memory loss). A record review of Resident #2's Quarterly MDS assessment, dated 03/10/2025, reflected the resident had a BIMS score of 9, which indicated moderate cognitive impairment. A record review of Resident #2's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area. Page 1 of 2 455638 455638 04/21/2025 Greenview Nursing and Rehabilitation 401 Owen LN Waco, TX 76710

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of the facility's provider investigator report dated 04/08/2025 reflected the facility did not report the alleged verbal sexual abuse allegations within 24 hours to the State Survey Agency (HHSC). The Provider investigator report revealed the incident occurred on 04/05/2025 at 2:30 pm. The ADM reported the incident to HHSC on 04/05/2025 at 12:41 pm. Attempted interview with ADON on 04/21/2025 at 12:53 pm and 4:00 pm was unsuccessful. Voice message was left for the ADON to return call. The ADON did not return call before or after the facility exit on 04/21/2025. During an interview with Resident #2 on 04/21/2025 at 1:05 pm, stated that he was safe and did not have any issues with Resident # 1. Resident # 2 stated that he and Resident # 1 was both in wheelchairs, and Resident # 1 came down the hall, date and time not recalled, and told him to pick which side he was going to be on. Resident # 2 stated he did not mean any harm but he pushed Resident # 1 toward her chest area to move her out of his way so he could get by. During an interview with Resident # 1 on 04/21/2025 at 1:30 pm, stated she was safe, and she did not have any issues with Resident #2. Resident # 1 stated she was coming down the hallway, could not recall the date, and she just only told Resident # 2 which side of the hall he was going to be on. Resident # 1 stated Resident # 2 had said something to her (can't recall), and he pushed her chest area. Resident # 1 stated she was not injured or hurt but she did let staff know what had happened. During an interview with the DON on 04/21/2025 at 4:03 pm, stated the ADM was responsible for reporting the incident with Resident # 1 and Resident # 2 on 04/04/2025. The DON stated it was expected for the ADM to report timey to prevent any further abuse. During an interview with the ADM on 04/21/2025 at 4:11 pm, stated that when the incident had happened on 04/05/2025 at 2:30 pm he immediately started investigating. The ADM stated Resident # 1 and Resident # 2 were both interviewed, and he was getting conflicting stories from each of the residents. The ADM stated that it was first told Resident # 2 had pushed Resident#1 out the way to get by when they were in the hallway. The ADM stated then it was told Resident #2 had hit Resident # 1 in the breast area when they were in the hallway. The ADM stated he did not report to the state as alleged abuse until 04/08/2025 after the stories kept on changing. The ADM stated the report should have been made to HHSC on 04-05-2025 when the incident had occurred. The ADM stated he was responsible for reporting the incident to the state timely. The ADM stated it was expected to report alleged abuse to HHSC within 24 hours to prevent further abuse. A record review of the Long-Term Care Regulation Provider Letter dated August 29, 2024 facility's reflected Abuse, Neglect, Exploitation, Misappropriation of Resident Property and other incidents that a Nursing 455638 Page 2 of 2