Health inspection·November 26, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, or injuries of an unknown source were reported immediately but not later than 24 hours after the allegation was made for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to report to the State Survey agency of an injury of unknown origin when Resident #1 was diagnosed with a L1 transverse process fracture (a break in one of the bony projections on the sides of the vertebrae). This deficient practice could place residents at risk of abuse and neglect. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, hemiplegia (paralysis on one side of the body), generalized anxiety disorder, and morbid obesity. Review of Resident #1's quarterly MDS assessment, dated 10/03/24, reflected a BIMS score of 6, indicating he had a severe cognitive impairment. Review of Resident #1's quarterly care plan, dated 10/07/24, reflected he presented with cognitive impairment secondary to diagnosis of TBI and dementia with an intervention of asking yes/no questions in order to determine his needs. It further reflected he had paint r/t chronic physical disability with an intervention of anticipating his need for pain relief and responding immediately to any complaint of pain. Review of Resident #1's hospital discharge paperwork, dated 09/27/24, reflected the following: Hospital course: [Resident #1] admitted for low back pain and knee pain. Found to have L1 transverse process fracture. Review of Resident #1's progress notes, dated 09/30/24 and documented by LVN A, reflected the following: Transferred from hospital . has fx L1 and L knee contusion . Page 1 of 2 675862 675862 11/26/2024 Avir at Park Bend 2122 Park Bend Dr Austin, TX 78758

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/26/24 at 12:30 PM, the DON stated he did not believe Resident #1's fracture was a reportable incident because they did not know when it happened, how it happened, or how long it had been there. He stated the hospital, orthopedist, and MD could not confirm when it happened. He stated he (Resident #1) had not had any recent falls at the facility. He stated he did not see it as an injury of unknown origin but more so as an injury of unknown time. The ADM stated she had heard the fracture had not been confirmed, but if she had known he had an actual fracture, she would have reported it to HHSC . The ADM stated the importance was to ensure they were addressing his pain, care, and to ensure there had not been any instances of abuse or neglect. Review of the facility's Abuse Investigation and Reporting Policy, Revised July 2017, reflected the following: All reports of resident abuse, neglect . injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . 675862 Page 2 of 2