Health inspection·December 6, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few identified for fear of retaliation, revealed concerns regarding a friend who also lived at this facility. This resident felt Resident #1 was not being treated fairly as he was no longer permitted to go with the rest of them on outings because he was a double amputee. The resident stated staff have told them it was because of something that happened at another facility. In an interview on 12/6/24 at 11:28 am Resident #1 stated his main concern was that he had been, discriminated against because of my disability. He stated he had been at the facility for years and all the sudden months ago, they told him he could not ride in the facility van because he was a double amputee. Resident #1 stated it was him watching his friends leave and go to the store without him, like I am some kind of loser. He was told it was now a policy because of something that happened at another facility when a double amputee got hurt and was now suing. Resident #1 stated he was mad because, we are not all the same person just because we are double amputees. He stated he cannot spend that time with his friends, it was fun and there was not a whole lot of fun available to him these days. Resident #1 stated Now they (the facility staff) say it is for my safety they know I'm mad I have let everyone know. In an additional interview at 12:30 pm with Resident #1, he stated he does know that he can take a hired van that is not the facility's. He asked, how is that supposed to make me feel? I am the only one here that is not allowed. He stated he just has not gone on outings since they started this new rule. In an interview on 12/6/24 at 2:02 pm with CNA A he stated Resident #1 has complained to him about not being allowed on the company van. CNA A stated if there was an outing, they would make sure he has a ride with a transportation company, but there was a policy that he cannot ride in the facility van. CNA A said it was for Resident #1' own safety. He stated he was not sure, but he thought that something had happened at another facility which caused the change in policy . In an interview on 12/6/24 at 2:35 pm, CNA B stated she was not sure how long ago it was when they started saying Resident #1 could not ride in the facility van, but she thought it was a few months ago. She stated she was told Resident #1 could not ride because it was a safety issue. She stated that he could not be protected by the seatbelt in the van and, that the new policy was to protect the resident. CNA B stated they would provide a safe ride with another transportation company . In an interview on 12/6/24 at 2:49 pm with ADON C he stated Resident #1 had not expressed any concern to him about the van policy. ADON C stated he was aware that Resident #1 was not supposed to ride in the facility van, but they could call a transportation service . In an interview on 12/6/24 at 3:01 pm with LVN D, she stated Resident #1 had not spoken to her about his concerns regarding not being allowed to ride in the facility van. LVN D stated the policy said he could not ride because it was a safety risk for someone that did not have at least one leg to balance themselves. In an interview on 12/6/24 at 4 :22 pm with the facility SW revealed she had worked at the facility for about 10 months and during that time Resident #1 had refused to do a BIMS assessment and stated the questions were stupid. The SW stated she asked today and told him the interviewer was asking what the results of a BIMs assessment were, so he agreed to answer the questions. She stated he answered all the questions correctly. The SW stated she knew Resident #1 was unhappy about not going on the trips to the local retail store, but that it was his choice. She stated she thought the facility would arrange transportation for him with the transport company, but he had refused to utilize the alternate transportation. She stated she went to the store for him every Friday and purchased the items he requested . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 2 of 4 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 12/06/2024 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 12/06/24 at 12:00 pm, 3:10 pm, and 5:10 pm with the facility Adm, she stated Resident #1 was not allowed to ride in the facility van. She stated they could not ensure the safety of a double amputee. The Adm stated they had talked with Resident #1 about providing alternate transportation with a contracted medical transport company. The Adm stated she was not aware of any difference with how transportation was accomplished using the transport company, other than they (the facility) had a policy saying they could not transport the resident and the medical transport service would transport him. The Adm stated she did consider the policy to be for the protection of the resident and not for the facility's protection. In a continued interview at 3:10 pm, the Adm stated that their residents did not socialize on the van during trips. She stated the facility van manufacturer told the facility the seatbelts in the van were not adequate for a double amputee. Continued and final interview at 5:10 pm, prior to the exit, the Adm stated there was not a specific sentence in the policy that read double amputees were not allowed on the van, but she had highlighted in the policy a section that read about the facility ensuring the residents' safety . In an interview on 12/09/24 at 11:45 am with a driver/worker at the alternate transportation company used by the facility, she stated they used a normal van for transportation. They did not have special procedures or equipment for a person that was a double amputee. Record review of the facility's policy, last updated 8/2024 (with no date of the month noted) and entitled, Driver and Vehicle Safety Policy, with the subject highlighted Resident Wheelchairs in transportation revealed: Geri-chairs and scooters may NOT be used for transportation in the company vehicle. Wheelchairs, including tilt wheelchairs, used for transportation should meet current ANSI and Society of Automotive Engineers (SAE) standards for wheelchairs used in motor vehicles. Wheelchairs should have a frame which has four securement points for tie down straps and can withstand an impact or accident. Motorized wheelchairs may be used for transport; they should be turned off before loading the wheelchair into the lift or van, and should remain off for the entire trip, until the wheelchair has been completely unloaded from the van. Continued review revealed the 35-page policy did not contain any documentation about van use restrictions for residents with double amputations. Record review of the facility's policy, updated 2/2021 and entitled, Resident Rights, with the policy statement: Employees shall treat all residents with kindness, respect, and dignity. Policy interpretation and implementation includes, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 3 of 4 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 12/06/2024 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 0561 be free from abuse, neglect, misappropriation of property, and exploitation; Level of Harm - Minimal harm or potential for actual harm d. Residents Affected - Few be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; e. self-determination On 12/6/2024, the facility failed to provide documentation of the van manufacturer's report to the facility that the van seatbelt was not adequate for a double amputate when this documentation was requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 4 of 4