Inspection·April 15, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm nurse and the DON that CNA A had told the resident she would not put a fitted sheet on her bed just to have the resident defecate on it (in foul language). Resident #1 stated she could not help having diarrhea and needed sheets on her bed. The CNA refused and did not put any bedding on the bed. The medical director and resident's RP were notified (note DON already aware). The Social worker was notified and spoke with the resident. A Skin assessment for Resident #1 did not reveal any signs of injury. Residents Affected - Few In an interview and observation on 4/15/24 at 10:25 am, Resident #1 stated she did not recall the incident where a CNA spoke badly to her. She stated she could transfer back to bed on her own. There were notices at her bedside reminding her to ask for help and use her call light. The surveyor notified the charge nurse that Resident #1 was attempting to self-transfer back to bed. In an interview on 4/15/24 at 10:45 am, the Administrator stated the Housekeeper and Transport Aide reported the verbal abuse of Resident #1 right away. The administrator stated the witnesses informed her the aide used foul language and refused to make up the resident's bed. The administrator stated the social worker reported to her CNA A had threatened to retaliate against the resident if she reported any problems. In an interview on 4/15/24 at 11:50 am, Housekeeper B (who overheard the incident) stated CNA A told Resident #1 she would not put a fitted sheet on her bed because the resident would just shit on it anyway. Housekeeper B stated the CNA used a sarcastic tone and gave the impression of being lazy. She stated she had not heard anyone else complain about the rudeness of staff. In an interview on 4/15/24 at 12:27 pm, CNA G stated she was working on the day the incident occurred. She stated Resident #1 was forgetful and did not comply with care sometimes. She stated Resident #1 was once a resident of Memory Care and would forget to use her call light to ask for assistance. She stated Resident #1 required frequent checks and bed linen changes. She stated it was unacceptable to refuse to help a resident, to refuse to change a bed and yelling at a resident was abuse. In an interview on 4/15/24 at 12:33pm, CNA A stated she was in a situation with multiple residents at the time of the alleged incident. She stated she helped Resident #1 return from the dining room and then went back to assist others. She stated she returned with Resident #2 (#1's the next room up the hall) who was bleeding profusely from her thumb. CNA A stated she did not use foul language with Resident #1 and only stated she would be right back as soon as she finished helping Resident #2. She stated the nurse declined to help Resident #2. CNA A stated she applied a band aide from her own supplies to Resident #2 because the bleeding from a cut to her thumb was so bad. CNA A stated there was so much blood she helped Resident #2 change her clothing. Observation of Resident #2 on 4/15/24 at 12:45 pm revealed she had no band aides or dressings to her fingers. Resident #2 was resting quietly in bed and did not reply to surveyor when he introduced himself. In an interview on 4/15/24 at 12:50 pm, LVN W stated Resident #2 had a history of chewing her fingernails down to the nub and would occasionally have some bleeding. She stated Resident #2 had no incidents of bleeding in the last 30 days. LVN W stated she worked with Resident #1 frequently and she was forgetful and needed frequent reminders to stay on task. She stated the resident had memory problems and wanted to do things for herself, which had caused a number of falls. She stated Resident #1 was usually pleasant and it would not be normal for her to argue with an aide. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 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 675101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Giddings 1400 N Main St Giddings, TX 78942 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 4/15/24 at 1:15 pm, the DON stated she was not sure what the CNA cussing out Resident #1 was thinking, she stated Resident #1 wanted things her way but was cooperative with most people. She stated Resident #1 needed frequent reminders to do most of her ADLs and would refuse sometimes, but you could just reapproach her in a few minutes. Review of the Progress Notes for Resident #2 reflected no mention of bleeding or dressing r/t to skin damage since a fall on 2/27/24. Review of the Facility Abuse Neglect and Exploitation Policy dated 10/2023 reflected verbal abuse of a resident would be substantiated if overheard by other residents or staff. Review of the Personnel File of CNA A reflected she was educated on prevention of Resident Abuse and Verbal abuse. CNA A was hired on 11/15/2023 and was appropriately screened through EMR and licensing. No previous problems had been reported. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675101 If continuation sheet Page 3 of 3