Health inspection·February 6, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was susceptible to wandering risk related to decreased safety awareness, confusion and wandering behavior. Goal to remain free of injuries associated with wandering behaviors thru this review period. Record review of care plan reflected Resident #1 needs assistance as he has poor eyesight. Record review of care plan initiated 10/10/2024 with a goal date of 04/09/2025 reflected Resident #1 susceptible for ADL self-care performance deficit related to legal blindness. Intervention/task for toilet use: the resident requires extensive assistance by (x1) staff for toileting. Transfers: the resident requires extensive assistance by (1-2) staff to move between surfaces as necessary. Review of the care plan reflected Resident #1 is a wanderer related to disoriented to place, impaired safety awareness. Resident wanders aimlessly, significantly intrudes on the privacy or activities. Goal reflects the residents' safety will be maintained through the review date. Record review of care plan reveals resident has a communication problem related to cognitive communication deficit, hearing loss. Intervention/task to ensure/provide a safe environment. Care plan revealed the resident is a high risk for falls related to confusion, incontinence, poor communication/comprehension, unaware of safety needs, vision/hearing problems, wandering. Goal: the resident will not sustain serious injury through the review date. Record review of a video revealed on 01/28/2025 at 10:46 pm that was 2:32 minutes long, revealed Resident #1 get out of bed and bump into chair that care aide was using for his feet as a recliner. Resident then goes toward the sink and the care aide woke up because of the noise from him bumping into furniture. CNA A reached over and grabbed a sandwich from the side table next to him and handed it to the resident. Resident #1 returned to his bed, sat down and began to eat his sandwich and laid back down with food in his mouth. CNA A was sitting in his chair on the opposite side of the room. The video only showed his feet propped on a second chair that was being used as a recliner. Record review of a video revealed on 01/29/2025 at 4:42 pm that was 4:15 minutes long revealed Resident #1 getting up out of bed and walked towards the restroom where care aide was sitting with his feet propped on another chair as a recliner set up. Resident #1 bumped into the chair and care aide woke up and began to wipe his eyes with his hands, he then reached over and grabbed Resident #1 by his t-shirt and directed him towards the restroom door. CNA A checked his personal phone and returned to sleep. Video Resident #1 was using the restroom with the door open, and his back was visible in the video as he was standing up urinating. CNA A was asleep in the video with his feet propped up in chair and the resident bed side table was in front of him. Video then revealed resident turn around, pulled his pants down and sat on the toilet. CNA A's eyes were closed. During telephone interview on 02/06/2025 at 12:51 PM CNA A stated he was not asleep during his 1:1 shift with Resident #1. CNA A voiced it was not good to fall asleep during shift. CNA A verbalized his boss has not told him when he can return to work and that he was not sure when they will call him back to work. CNA A stated he knows he didn't do anything when he was with the resident in the room. During an interview on 02/06/2025 at 1:21 PM LVN B stated it was not appropriate for staff to be asleep on the job. LVN B stated she has not noticed any staff sleeping on the job and negative effects that could happen to resident if staff were asleep on the job would be they could have choking hazards and residents could fall. During an interview on 02/06/2025 at 2:09 PM with housekeeper A and Housekeeper Supervisor A (Housekeeper Supervisor A was translating for housekeeper A), Housekeeper A voiced she did notice a staff member asleep in a resident's room on one occasion. Housekeeper A stated she was not sure how long ago that was but does recall mentioning it to her supervisor. Supervisor voiced he does recall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 2 of 5 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 02/06/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few housekeeper A reporting it to him but could not recall the date. Housekeeper supervisor A voiced that he did tell one of the nurses but does not know her name. Housekeeper supervisor A voiced he does recall it was sometime during the day around noon time. Housekeeper A voiced she went to knock on Resident #1 room to clean it and when no one answered she knocked again for a second time. Housekeeper voiced no one answered so she entered the room and noticed Resident #1 and CNA A were asleep. Resident #1 was in his bed and CNA A was in a chair by the restroom and CNA A woke up, looked at his phone and went back to sleep. Housekeeper voiced Resident #1 was asleep the whole time, so she was very quiet while cleaning up his room and then exited shortly after once completed. During an interview on 02/06/2025 at 2:33 PM CNA B stated it was not appropriate for staff to sleep on the job. A negative outcome for staff sleeping on the job would be that staff would not be there for residents if they're not alert. Residents could accidentally choke, and staff would not be aware if they fell asleep on the job or they can fall attempting to get up on their own. CNA B stated she has not noticed any staff sleeping on the job, if she did notice any staff sleeping on the job, she would report it immediately. CNA B voiced she has worked with Resident #1, and he was legally blind. CNA B said he has already gotten used to his room but sometimes he will bump into things, and staff just need to redirect him. If Resident #1 got out of bed, he could get out of the room and he could go into another room and get hurt. During an interview on 02/06/2025 at 2:48 PM with Resident #1 FM. The FM stated she was watching the monitoring device that is set up in resident #1 room. The monitoring device recorded CNA A asleep in Resident #1 room. FM stated CNA A sets up chair like a recliner and has a pillow and sleeps while providing 1:1 for resident #1. FM stated CNA A places furniture in the way and Resident #1 is blind and he has difficulties getting to the restroom and at one point resident #1 gets up and asks for a sandwich. FM verbalized she noticed can A grab Resident #1 by the shirt CNA stays put in his chair while redirecting Resident #1 to the restroom. The FM voiced she reported this to the facility ADM and sent her the videos. The ADM requested that FM send the videos again. FM stated she does not feel like Resident #1 was safe with CNA A working at the facility. FM stated Resident #1 has already had a stitch put in his head from hitting the wall. FM stated overnight was not good for Resident #1 . FM stated she does not know if the facility is still allowing CNA A to watch Resident #1. FM stated I prefer they don't. I've seen everyone care for resident #1 and it's okay it was just that one incident that was disturbing (when CNA A grabbed Resident #1 by the T-shirt) instead of just moving the furniture out of the way so resident #1 can pass thru to the restroom. In an interview on 02/06/2025 at 2:55 PM CNA C stated she was usually the staff member that provides 1:1 with Resident #1 . CNA C stated one morning when she arrived for her morning shift no one was in the room and Resident #1 was alone. CNA C voiced she was informed by other staff that CNA A left home early during his shift and no one went to sit in the room with Resident #1 for 1:1. CNA C stated she informed the ADON and Wound care nurse. CNA C voiced she has not seen CNA A asleep but voiced she has been informed by the housekeeper that CNA A was asleep. CNA C verbalized it was not appropriate for staff to sleep on the job. CNA C voiced if she ever noticed staff asleep on the job, she would bring it up to the staff member and then inform the charge nurse or ADON. CNA C stated that it could be very harmful to the resident if staff were asleep on the job because the residents could fall, get hurt or choke if they were eating something. In an interview on 02/06/2025 at 3:34 PM the ADON stated he has not been informed by staff that any staff were sleeping on the job or when watching resident #1 during 1:1. The ADON voiced resident #1 was active and required 24-hour care and there was no way someone can sleep in that room. The ADON verbalized it can be harmful if someone was asleep while watching resident #1 because a lot of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 3 of 5 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 02/06/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few things can happen because resident #1 needs assistance. The ADON voiced it was not appropriate for staff to be sleeping on the job. In an interview on 02/06/2025 at 3:42 PM the Wound care nurse stated no one has reported to her that staff have been sleeping on the job or while watching resident #1 during 1:1. The Wound care nurse voiced resident #1 was blind, autistic and had intellectual disabilities, therefore, resident #1 gets easily frustrated when he doesn't know where he was at. The Wound care nurse voiced that resident #1 can hurt himself if someone was asleep while watching him 1:1. The Wound care nurse voiced it was not appropriate for staff to sleep on the job and it can be harmful if someone was sleeping on the job. During an interview on 02/06/2025 at 4:18 PM the DON said she has not been informed of staff sleeping on the job. The DON voiced it was not appropriate for staff to sleep on the job and if she was informed of staff sleeping on the job she would investigate and put the staff member on suspension pending the investigation. If it was found to be true, the staff member would be terminated. The DON stated staff were expected to do their job, answer call lights and take care of residents while working. The DON voiced she has not given an in-service on sleeping on the job, but they do give Abuse and Neglect trainings and the topic of sleeping on the job is brought up as an example of abuse and or neglect. During an interview on 02/06/2025 at 4:30 PM the ADM stated that she has not ever been informed of staff sleeping on the job. The ADM stated staff were not allowed to sleep on the job and if staff did fall asleep during their shift several things could happen depending on where they were sleeping. If ADM was told that a staff member was sleeping on the job, she would get a hold of the staff member and suspend them with possible termination. The ADM stated an in-service for sleeping on the job was given this morning. The ADM stated the investigation for resident #1 was still on-going because she doesn't have any record or video showing CNA A asleep while providing 1:1 for resident #1. Record Review of Policy for resident 1:1 monitoring on 02/06/2025 at 3:45 PM revealed -Purpose: To prevent injury to patient by maximizing environmental safety. Procedure: Precautions will be implemented for patients/residents who have behaviors that has escalated, and immediate interventions are required for the safety of the resident, staff and/or other residents. If the nurse is concerned about the patient's safety, the following steps will be implemented: 1. Immediately place the resident on Constant Supervision At no time should the resident be left unattended Record review of in-service started on 02/06/2025 over no sleeping on the job has been initiated for staff. Resident #1 was not in the in-service since he was still on suspension from his job duties for the current investigation the facility was completing. Review of Hospitality Aid last updated 03/2020 Job Summary The Hospitality Aide performs non-nursing, non-direct resident care duties under the supervision of licensed nursing personnel and assists in maintaining a positive physical, social and psychological environment for resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 4 of 5 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 02/06/2025 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 0689 Job Description Level of Harm - Minimal harm or potential for actual harm 1-on-1 with residents who have behavioral challenges or need socialization Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675596 If continuation sheet Page 5 of 5