Health inspection·July 11, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance, cognitive communication deficit, delusional disorder, and major depressive disorder. Review of Resident #2's quarterly MDS assessment, dated 05/01/2023, reflected the BIMS of 15, reflecting intact cognition. Residents Affected - Some Review of Resident #3's face sheet dated 06/11/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including schizophrenia, post-traumatic stress disorder, and persistent mood affective disorder. Review of Resident #3's quarterly MDS assessment, dated 05/13/2023, reflected the BIMS of 15, reflecting intact cognition. Review of Resident #4's face sheet dated 06/11/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, cerebral infarction (A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), and mild dementia. Review of Resident #5's face sheet dated 06/11/2023 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes with other diabetic kidney disfunction, major depressive disorder, chronic kidney disease, and [NAME] Lymphoma (type of cancer that affects the lymphatic system, which is part of the body's germ-fighting immune system). Review of Resident #5's quarterly MDS assessment, dated 06/03/2023, reflected the BIMS of 15, reflecting intact cognition. Interview on 07/11/2023 at 2:05 PM with Resident #2 revealed that in 06/08/2023 she had a 12 pack of chocolate pudding and a bag of chips missing from her room. She revealed she knew Resident #1 took them because LVN A told her she found the 12 empty pudding containers and the empty bag of chips she described to LVN A in Resident #1's room. Resident #2 revealed she told the administrative staff, and she was reimbursed for the cost of the items. She revealed she no longer leaves her snacks out but keeps them in a tightly closed bag. Interview on 07/11/2023 at 1:00 PM with Resident #3 revealed that Resident #1 had stolen snacks from her room two times. The first time LVN A told Resident #3 she saw Resident #1 leaving her room with the food. Resident #3 revealed she had gone to Walmart the day prior and had purchased a King-Sized Lucky Charms cereal bar, two 20-ounce bags of Ruffles Sour Cream and Cheddar potato chips, a 20-ounce bag of Chex Mix Cheddar Flavor, Ritz Crackers, and a package of strawberry wafers. Those items were found with Resident #1. Resident #3 revealed she discussed the theft with LVN A but not the ADM. The second time Resident #1 stole snacks from Resident #3 a photo was captured of Resident #1's face on the video camera from Resident #'3 room and again LVN A told Resident #3 she witnessed Resident #1 leaving her room with food items. The 2nd time Resident #3 was missing a ½ gallon of milk, protein shakes, and chips found with Resident #1. Resident #3 reported the incident to the ADM. Resident #3 revealed she felt angry and violated because Resident #1 went through her drawers to find the snacks and that was an invasion of her privacy. Resident #3 revealed that she told Resident #1 if you go in my room again, I am going to, stomp a mud hole in you and now Resident #3 thinks Resident #1 is scared. Resident #3 revealed she closes her door when she leaves her room. Interview on 07/11/2023 at 4:02 PM with Resident #4 revealed she was a former roommate of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 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 675596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Valley Rehabilitation and Healthcare Center 4501 Dudmar Dr Austin, TX 78735 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #1. Resident #4 revealed when she was roomed with Resident #1, she had 5 sodas in her refrigerator and when she woke up the next morning they were gone. She did not see Resident #1 drink the sodas, but she heard the pop of the sodas open during the night and a nurse (Resident #4 does not remember the name of the nurse) came in the morning and said, I hope you didn't let Resident #1 drink all those sodas. Resident #4 revealed it made her feel like she could not have anything to herself. She revealed she did not report it because she did not want it to escalate into an argument. Interview on 07/10/2023 at 9:34 AM with Resident #5 revealed that he knew, but did not see, Resident #1 go into other people's rooms and steals things. He revealed he caught Resident #1 when she tried to enter his room and he asked her not to go into his room. He revealed that it made him feel kind of mad because he had to peak around the corner to make sure she did not go into his room. Interview on 07/11/2023 at 11:18 AM with LVN A who revealed that she caught Resident #1 taking snacks from Resident #3's room on two occasions. LVN A knew the snack items she found with Resident #1 were from Resident #3 room because LVN A helped Resident #3 put them away the day prior. The second time LVN A witnessed Resident #1 leaving Resident #3's room Resident #1 used another resident's wheelchair and had the items, a ½ gallon of milk, protein shakes, and chips in her lap. LVA revealed that she watched Resident #1 to prevent her from taking snacks from other resident but no interventions, that she was aware of, had been made but she knows that the ADM addressed the thefts. LVN A revealed she knew that Resident #1 is PASRR positive and had an intellectual disability, but LVN A felt Resident #1 knows right from wrong. LVN A revealed that when she talked to Resident #1 about the thefts, she denied the thefts or said nothing. Interview on 07/11/2023 at 12:00 PM with Resident #1 who denied she went into other residents' rooms and took food and stack items. Interview 0n 07/11/2023 with the ADM revealed that the ADM knows that Resident #1 had stolen snacks from Residents #2 and #3 but did not know Resident #1 had taken the sodas from Resident #4 or attempted to go into Resident #5's room without his permission. ADM revealed that when she spoke with Resident #1 about the thefts, Resident #1 either denied the thefts or said nothing. ADM revealed she had a difficult time developing an intervention for Resident #1's thefts of snacks. Review of Facility Abuse Prohibition Policy dated 03/2023 reflected the facility will prohibit the misappropriation of property or finances of residents. Resident to Residents Incidents: The interdisciplinary team with make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following: Immediate discharge from the facility due to potential for harm to other residents. Can the behavior be controlled by location monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 3 of 3