Health inspection·October 9, 2023

F 0609 facility . Level of Harm - Minimal harm or potential for actual harm During an interview on 10/06/2023 at 7:32 PM, the DON stated the facility did not report the allegation of abuse to the state survey agency due to collaborating with the PASSR case manager on Resident #1's allegation of abuse. The DON stated she was told by the PASSR case manager that they would be notifying the state survey agency of Resident #1's allegation of abuse. The DON stated the PASSR personnel were not employees of the facility nor affiliated with the nursing facility. The DON stated the facility and PASSR personnel worked collaboratively regarding Resident #1's allegation of abuse. The DON stated Resident #1 was asked about his allegation of abuse but did not name a staff member. The DON stated Resident #1 notified the MDS nurse and Administrator during a PASSR meeting, to which the Administrator began an investigation into Resident #1's allegation. The DON stated this morning, of 10/06/2023, she called PASSR personnel to notify them of the facility's ongoing investigative actions. The DON stated the conclusion to the facility's investigation was inconclusive and determined there was no threat to the safety of the residents. The DON stated it was at the discretion of the administrator to make the decision to notify the state survey agency. The DON reiterated it was ultimately up to the administrator to notify the state survey agency of the allegation of abuse. The DON stated, according to the facility's policy, if the facility suspected abuse which included injuries, then they were to notify the state survey agency and other agencies. The DON stated once the investigation concluded within the 24 hr window, the results were inconclusive, and did not report the allegation of abuse to the state survey agency due to the PASSAR case manager already reporting the allegation to state, and their investigation's inconclusive conclusion . The DON stated ultimately it was the responsibility of the Administrator to notify the state survey agency regarding the allegation of abuse. Residents Affected - Few During an interview on 10/07/2023 at 2:49 PM, the MDS Coordinator stated they had Resident #1's annual PASSR meeting. Once the meeting concluded Resident #1 left the meeting room and then re-entered, he proceeded to state while visiting a female friend, a unknown CNA spoke to him using profane words, and stated the CNA stated she would shoot him. The MDS Coordinator stated Resident #1 stated he felt comfortable living at the nursing facility but felt threatened. The MDS Coordinator stated Resident #1's story started to shift to another conversation and had a salad bowl (various subjects) type of conversation. The MDS Coordinator stated she attempted to refocus Resident #1, but saw he had a blank stare when she talked to him, and Resident #1 went on to speak about different subjects. The MDS Coordinator stated Resident #1 could not pinpoint exactly what day/date the allegation occurred but Resident #1 stated it may have been 1-2weeks ago. The MDS Coordinator stated Resident #1 was known to fabricate stories. The MDS Coordinator stated the facility launched an investigation into Resident #1's allegation of abuse and stated the PASSR case manager stated she was going to be reporting Resident #1's allegation of abuse to the state survey agency. The MDS Coordinator stated since the PASSR case manager was mandated to report Resident #1's allegation of abuse to the state survey agency, she believed the nursing facility would also be obligated to report any allegation of abuse to the state survey agency. The MDS Coordinator stated the Administrator was going to do an investigation, and when the investigation concluded the Administrator was going to call their corporate office. The MDS Coordinator stated the facility started the investigation on October 5th. The MDS Coordinator stated the facility policy stated if there was any allegation of abuse it needed to be reported within 24hrs and proceeded to state the nursing facility took all allegations of abuse seriously, and even if they were lying the facility needed to notify the state survey agency. The MDS Coordinator stated the Administrator is responsible for notifying the state survey agency of all allegations of abuse. During an interview on 10/09/2023 at 10:47AM with the Administrator, he stated he was notified of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455697 If continuation sheet Page 2 of 3 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 455697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Corpus Christi 202 Fortune Dr Corpus Christi, TX 78405 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the allegation of abuse on 10/05/2023 at 3:30 PM after the conclusion of Resident #1's PASSR meeting. The Administrator stated Resident #1 began to exhibit out-of-the-box (abnormal) episode and began to voice his concern of a staff member threatening him with a gun and switched the subject of the meeting to his girlfriend. The Administrator stated, in conjunction with Resident #1's PASSR case manager, Resident #1 may have been experiencing delusional episodes. The Administrator stated when he was notified of the allegation of abuse, he facilitated an investigation into Resident #1's allegation of abuse. The Administrator stated once the investigation concluded, it was determined the allegation was inconclusive and determined this allegation of abuse was not reportable to state . The Administrator stated he was unaware of the allegation of verbal abuse regarding Resident #1 being cussed at. The Administrator stated the PASSR case managers were not employed by the facility nor were they affiliated with the nursing facility. The Administrator stated the expectation of the facility was to report allegations of all forms of abuse within 24hrs from when the allegation was stated, however this allegation was not reportable to state. Record review of TULIP on 10/06/2023 at 5:30PM, reflected no TULIP report noted regarding the allegation of abuse for Resident #1 Record review of the facility's Abuse Investigation and Reporting policy, revised July 2017, reflected, .1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455697 If continuation sheet Page 3 of 3