Health inspection·February 5, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, comfortable and homelike environment, for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally threaten Resident #1 on 08/30/24. This failure placed resident at risk of abuse. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia, major depressive disorder, generalized anxiety disorder, intracranial injury with loss of consciousness (brain injury affecting cognition and behavior), hemiplegia (paralysis on one side of the body), morbid obesity due to excess calories. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderately impaired cognition. It reflected he was completely dependent on staff for toileting hygiene. Record review of Resident #1's care plan, dated 03/13/24, reflected the following: [Resident #1] is/has potential to be verbally aggressive (calling out, use of profanity) secondary to diagnosis of TBI. I will demonstrate effective coping skills through the review date. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc . Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Psychiatric/Psychogeriatric consult as indicated. Two staff care providers at all times. Record review of an automated electronic monitoring video recording , dated 08/30/24, reflected the following exchange while CNA A helped Resident #1 get dressed: CNA A: Let go to put your jeans up, please! You're being difficult today. It's too much! Resident #1: Y'all gonna put my jeans on. CNA A: Stop holding yourself like that now I can put your jeans on. Long time ago. Come on, hold your hands. Page 1 of 3 675862 675862 02/05/2025 Avir at Park Bend 2122 Park Bend Dr Austin, TX 78758

F 0600 Resident #1: Don't rock the jukebox! Level of Harm - Minimal harm or potential for actual harm CNA A: Rock the juice box, what does that mean? Resident #1: Don't rock me! Residents Affected - Few CNA A: No one is rocking you! What does rocking mean?! Resident #1: Quit pushing me CNA A: Nobody's pushing you. I'm turning you. Resident #1: Quit pulling me CNA A: Turning! It's turn! Tuuurning! Resident #1: Whatever CNA A: Why are you yelling? Resident #1: Stop it! CNA A:You stop it. Stop yelling. Resident #1: *balls up fist and points it at CNA A* CNA A: What are you gonna do with that? Hit me! Watch! Hit me if you want! You gonna see. I got a hand too I'm gonna push you back. I don't care! You don't get the right to push me or punch me. I'm not playing with you! Record review of a psych note, dated 09/03/24, reflected the following: Behavioral meeting done with staffs and visit conducted per protocol. Mood assessed and reports gotten. No depression, anxiety, insomnia, loss of appetite, psychosis mentioned or reported. There has also been no reports of suicidal ideations. Record review of a psych note, dated 01/07/25, reflected the following: Behavioral round done at facility. No changes would be made today. There are no reports of depression, loss or increased appetite, insomnia. There are still some behaviors. no changes for now. During observation and an interview on 02/05/25 at 10:07 AM, Resident #1 was lying in his bed and said he was comfortable and not in any pain. He stated everyone at the facility treated him well, but his FM was always saying things. He stated he felt safe in the facility. He stated he did not know anyone with CNA A's name. He stated he did not remember anyone being abusive to him. During an interview on 02/05/25 at 10:30 AM, A FM for Resident #1 stated they looked at the video camera back in September 2024 and saw the video of CNA A threatening Resident #1. The FM stated they had not provided the video to the ADM due to not trusting the facility to intervene, but did not think CNA A worked at the facility anymore, because the FM had complained about CNA A and was under the impression CNA A had been fired. The FM stated they saw CNA A working at the facility on 01/01/25 675862 Page 2 of 3 675862 02/05/2025 Avir at Park Bend 2122 Park Bend Dr Austin, TX 78758

F 0600 and was concerned that she might have access to Resident #1 . Level of Harm - Minimal harm or potential for actual harm During an interview on 02/05/25 at 01:15 PM, the ADM stated she had not seen the video in which CNA A threatened Resident #1. She stated the FM for Resident #1 did show her another video in November 2024 that was poor customer service by CNA A but not threatening, intimidation, or abuse. The ADM stated they took CNA A off Resident #1's care after the video in November and in-serviced her about customer service, but the ADM was not aware of any previous or later incidents. She stated the threat in the video was not acceptable and would lead to CNA A's termination from employment. The ADM stated she wished the FM for Resident #1 had shown the video much sooner. The ADM stated Resident #1 did have a history of verbal and physical aggression toward staff, and many of her staff did not wish to work with him. The ADM stated she was the abuse coordinator and responsible for the abuse prevention program. She stated the potential negative outcome of a staff person speaking in a threatening manner to a resident was the resident might not feel safe in the community . She stated she had not seen a difference in Resident #1's behavior since the incident. Residents Affected - Few During an interview on 02/05/25 at 03:07 PM, the DON stated if he had seen the video of CNA A threatening Resident #1, she would have been terminated immediately. He stated he had not seen the video and was not aware of anyone from the facility seeing the video. The DON stated the ADM was the abuse coordinator, and he (the DON) was her back up abuse coordinator. He stated the entire facility staff was responsible for preventing abuse. He stated they ensured compliance through routine in-servicing, auditing, and frequent rounding. The DON stated they also heard from the resident council to prevent abuse and neglect. The DON stated the potential negative outcome of the failure exhibited in the video was emotional harm and it could have escalated to physical harm. The DON stated he had not seen any changes or decline in Resident #1. He stated Resident #1 frequently refused care, but they could usually go back in and provide care. He stated the staff were trained to walk away if he was being aggressive with them and reapproach later or have someone else reapproach. He stated he called and terminated CNA A's employment moments before (02/05/25 prior to 03:07 PM) and took her off the schedule. An attempt was made to interview CNA A by telephone on 02/05/25 at 03:17 PM. A voicemail was left, and no contact was returned as of 02/12/25. Record review of the 2024-2025 training transcript for CNA A reflected undated trainings on Resident Abuse and Managing Behaviors in the Dementia Resident. Record review of the facility's policy, dated 08/15/22, and titled Abuse, Neglect and Exploitation reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations, in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual resident's care needs, and behavioral symptoms. 675862 Page 3 of 3