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 Page 1 of 2 675931 675931 05/06/2023 Avir at Camp Wood 710 Hwy 55 Camp Wood, TX 78833

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the sheriff was called to ensure agency nurse did not come back to facility the next morning for his shift. The facility trained staff on Abuse/Neglect and caring for residents with behaviors. Interview on 5/6/2023 at 4:45 PM with the Administrator stated incident intake #421375 Abuse, should have been reported within 2 hours now that I am looking at the Abuse policy. The Administrator asked why he had not reported to the STATE within 2 hours, he stated he was out of town and was investigating what happened. Record review of the Abuse and Neglect Policy and Procedure (no date) revealed Purpose: to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, involuntary seclusion and misappropriation of resident's belongings or money. Reporting/Response: The facility policy and procedures on reporting is to follow sate guidelines as outlined in the provider letter #14-13-guidleines for Reporting Incidents and to answer all questions as outlined in the TDHS letter dated August 2014. 2.1 Incidents that a NF must report to HHSC and the Time Frames of Reporting, A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect, Type of Incident Abuse (with or without serious bodily injury). When to report: Immediately, but not later than two hours after the incident occurs or is suspected. Abuse: The negligent or willful infliction of injury, unreasonable confinement, or punishment with resulting physical or emotional harm or pain to resident. Staff treatment of residents The facility prohibits mistreatment, neglect and abuse or residents and misappropriation of resident property. 675931 Page 2 of 2