Health inspection·May 6, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Physical Abuse, in that: Agency CNA A physically Abused Resident #1 by dragging him on the floor and hitting Resident #1 three times in the back kidney area. Resident had a small, raised area to mid upper back and soft nodule to back of neck that occurred on 4/30/2023. This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting. The findings were: Record review of Resident #1's admission Record dated 4/30/2023 revealed he was admitted on [DATE]. He was [AGE] years old with diagnoses of Alzheimer's disease, dementia, bipolar disease. Record review of Resident #1's admission MDS dated [DATE] revealed Section C Cognition Patterns BIMS score was 0/15 (severely impaired), Section E Behavior revealed he did exhibit physical, verbal and other behaviors in 1-3 days, rejection of care, and wandering was exhibited 4-6 days. Record review of Resident #1's Base Line Care Plan dated 4/27/2023 revealed he was able to communicate with staff, understand staff, his vision/hearing was adequate, resident is alert, unable to recall name, place of birth, and date, answers in grunts, makes eye contact and was non-verbal, he required a wheelchair, he was always incontinent of bowel/bladder, resident was elopement risk. Record review of incident intake #421375, revealed the incident occurred on 4/30/2023 at 6:30 PM in the secure unit hallway, the Administrator first learned of incident on 4/30/2023 at 7:11 PM, the Administrator submitted on 4/30/2023 at 10:49 PM. The incident revealed agency CNA physically abused Resident #1. Record review of the provider investigation for intake #421375 revealed the investigation was on-going. The incident occurred close to end of CNA Tata's shift, and left the facility before the managers could tell him to leave the building. The facility protected Resident #1 and other residents in the facility with the following interventions, the agency CNA was not allowed back into facility and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675931 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 675931 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833 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)