Health inspection·November 18, 2025

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 interviews and record review, the facility failed to report allegations of abuse, neglect, exploitation, or mistreatment that did not result in bodily injury within 24 hours. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 2 (Residents #2 and #3) of 3 residents reviewed for abuse, neglect, and misappropriation of property, in that; The facility staff failed to report Resident #2 inappropriately touching Resident #3 that did not result in any bodily injury. This failure could place residents at risk for not having incidents investigated and reported as required and continued abuse and neglect which could result in diminished quality of life.The findings were: Record review of Resident #2's face sheet, dated 10/16/25, revealed that Resident #2 had a admission date 12/26/18 and an readmission date of 12/6/23, with diagnoses that included: dementia (mental decline caused by different diseases), Chronic obstruction pulmonary disease (damage to lungs), irritable bowel syndrome (uncomfortable or painful abdominal), atherosclerotic heart disease (plaque in the arteries), lack of coordination, congestive heart failure (heart unable to pump enough blood to meet body's needs). Record review of Resident #2's MDS, dated [DATE] revealed BIMS score of 00 (severely cognitively impaired). Resident does not have the ability to make self-understood or the ability to understand others. Ambulates using wheelchair, resident is always incontinent bowl and bladder. Smoker. Record review of Resident #2's Care Plan dated 9/18/25, revealed a focus area, I have cognitive loss, which affects my Short-term/Long-term memory and decision-making skills. I am at risk of further decline as my disease progresses. Interventions include encourage activities, plan frequent rest periods during ADLs, observe for signs of frustration and anxiety, provide cueing, prompting, use eye contact. Behavioral symptoms, resident exhibits sexual inappropriateness during showering and bathing and showering activities. He makes gestures to wash and dry private areas which has been assessed as capable of performing that part of care. Resident has attempted to inappropriately touch female residents. Approach to behavior, redirect when resident acts out, praise when resident displays appropriate behavior. SW is attempting to find better placement for resident to a men's unit. Record review of Resident #3's face sheet, dated 10/17/25, revealed that Resident #3 had a admission date 8/31/12 and an readmission date 7/28/25, with diagnoses that include: intracranial injury (brain injury caused by external force), intellectual disabilities (limitations in functioning, skills and learning abilities), dementia (mental decline), pseudobulbar affect (uncontrolled episodes of crying or laughing), muscle weakness, repeated falls. Record review of Resident #3's MDS dated [DATE], revealed BIMS score of 00 (severely cognitively impaired), extensive assistance (staff Page 1 of 3 675932 675932 11/18/2025 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provides weight bearing support) with transfers, bed mobility, and toileting. Record review of Resident #3's Care Plan dated 8/29/25, revealed a focus area, I have a history pulling on peoples(male/female) clothing and pinch them on the bottom, But I generally gravitate to male residents. Interventions, verbally redirect when displaying inappropriate behavior with male residents. Face resident when speaking, never assume resident knows what/or understands what was said. I have behavior symptoms. As evidenced by my wandering, related to my DX of Dementia. Interventions, assist me in reorientation to room and facility with verbal cues, encourage group activities. Record review of Resident #1's face sheet dated 10/16/25, admission on [DATE] with diagnoses that include pneumonia (inflames air sacs in lungs), severe obesity (excess body fat), chronic obstructive pulmonary disease (damaged lungs). Record review of Resident #1's MDS dated [DATE], revealed BIMS score of 14 (cognitively intact). Record review of Resident #14's face sheet dated 9/13/25, admission on [DATE], with diagnoses that include malignant neoplasm of prostate (skin cancer), cerebral infarction (stroke). Record review of Resident #14's MDS dated [DATE], revealed BIMS score of 15 (cognitively intact). During a interview on 10/17/25 at 1:30pm, Resident #14 stated he could not recall date or time but sometime last month, he was coming in from smoking and was in the dining room when he saw Resident #2 who was coming in from smoking also and was about 15 feet in front of Resident #14, going over to Resident #3 who was sitting next to the coffee bar. Resident #2 placed his hand between the legs over the clothing of Resident #3. Resident #14 told him to stop that, and Resident #2 removed his hand. Resident #14 stated that the incident lasted only a few seconds. Resident #14 told LVN M, who was sitting at the nurses' station, that Resident #2 was inappropriately touching Resident #3 and LVN M got up and went into the dining room immediately. Resident #14 stated that he thought Resident #1 witnessed the incident also. Resident #14 stated that he knows residents' rights and to report any concerns to the staff. Interview on 10/17/25 at 1:45pm, Resident #1 stated he could not recall date or time, sometime last month, that they were all coming in from smoke break and Resident #1 observed Resident #2 roll over next to Resident #3 and put his hand between her legs. Resident #1 stated that Resident #2's hand was above cloths. Resident #1 stated that Resident #14 yelled at Resident #2 to stop, and he did. Resident #1 stated that Resident #14 told the nurse. The nurse came into the dining room and removed Resident #2. Resident #1 stated that the incident happened fast, and Resident #3 did not seem to mind. Interview on 10/21/25 at 1:05pm, LVN M stated that Resident #14 told her that Resident #2 was inappropriately touching a female resident in the dining room, LVN M stated she walked into the dining room and found residents #2 and #3 sitting next to one another but was not touching. LVN M stated that she removed Resident #2 from the dining room and back to his room. LVN M stated she did not recall date or time, but stated it was earlier this month, stating it was after dinner and residents were returning from smoke break. LVN M did not document the incident in progress notes. LVN M stated that she assessed Resident #3 and found no injury. LVN M stated she did not report the incident to Admin/DON, LVN stated she did not know why she did not report. LVN M stated she has been in-serviced to recognize, prevent, and report ANE to Admin/DON. LVN M stated that she knows how to report and allegation of ANE. LVN stated no other staff witnessed the incident. Interview on 10/21/25 at 2:00pm, Administrator stated that she was unaware of any incident involving Resident #2 and Resident #3 until surveyor informed her. Administrator stated that Resident #2 was removed from the facility on 9/29/25 because of his behaviors towards female staff and attempt to grab other residents. Administrator stated if known, the allegations of inappropriate touching would be investigated and reported to HHS. Administrator stated that LVN M failed to report and will be in-serviced and disciplined accordingly. Record review on 10/21/25 revealed that Resident #2 was transferred to a all-male facility on 675932 Page 2 of 3 675932 11/18/2025 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/29/25. Interview on 10/21/25 at 2:15pm, the DON stated she was not aware of the incident between Resident #2 and Resident #3. The DON stated expectation was that staff report all allegations to Administrator and/ or DON, so allegations can be investigated and reported if needed. The DON stated that Resident #3 did not appear to be withdrawn, harmed or had any change of character. The DON stated that all staff have been in-serviced in reporting alleged abuse and neglect. The DON stated that LVN M will be re-in-service 1:1 with DON on reporting allegations of abuse and neglect. Record review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 04/2021. Policy Interpretation and Implementation,8. Identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident's property.9. Investigate and report any allegations within timeframes required by federal requirements. 675932 Page 3 of 3