Health inspection·June 5, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a verbal abuse alleged violation was thoroughly investigated with Resident #1 and Resident #2. The facility failed to investigate an allegation made by Resident #1 during a separate facility reported incident. Residents Affected - Few The facility failed to investigate Resident #1's allegation of verbal abuse, in a facility reported incident that involved Resident #1 and another resident. Resident #1 made an allegation of verbal abuse against Resident #2. This failure could place residents at risk to prevent further abuse, neglect, and exploitation; and it potentially prevents the facility to take corrective actions to prevent abuse, neglect, and exploitation. Findings included: Review of Resident #1's face sheet, dated 05/31/2024, revealed an [AGE] year-old-female with an initial admission date of 08/11/2021 and an admission date of 12/22/2022, with diagnoses of cellulitis (bacterial skin infection) of right lower limb, diabetes, muscle wasting, cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit), hypertensive heart and chronic kidney disease, depression, and unspecified dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). Review of Resident #1's annual MDS assessment, dated 04/17/2024, revealed a BIMS summary score of 12 indicating a moderate cognitive impairment. Review of Resident #2's face sheet, dated 05/31/2024, revealed a [AGE] year-old female with an admission date of 10/27/2022, with diagnoses of unspecified dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities), delirium ( serious change in mental abilities that causes confused thinking and lack of awareness of surroundings), muscle wasting, need for assistance with personal care, muscle weakness, cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit), and age related debility. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS summary score of 03 indicating a severe cognitive impact. Review of Resident #1's progress note, no date, revealed a nursing note dated 05/27/2024 at 15:45 Page 1 of 3 676267 676267 06/05/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (03:45 p.m.) created by LVN A stating, Note Text: Alert and it was reported to write that resident had thrown a cup of cold water on another resident. Resident admitted that she did throw a cup of water on the other resident (Resident #2) because she always talking sexual talk to her (Resident #1) and she (Resident #1) does not like it. Review of Resident #2's progress note, revealed a nursing note dated 05/27/2024 at 15:45 15:45 (03:45 p.m.) stating, Note Text: Alert and another resident (Resident #1) threw a small blue cup of cold water on this resident (Resident #2) because this resident was talking to the other resident. further note revealed, No c/o (complains of) pain/discomfort noted. No apparent injuries noted. Record review of the Facility's incident and accident report, dated 05/30/204, revealed Resident to Resident incident that listed Resident #1 and Resident #2 both dated and timed 05/27/2024 at 03:45 p.m. Interview on 05/31/2024 at 10:10 a.m., when asked if she was afraid of any staff or any residents, Resident #1 stated, no I'm (I am) not scared, I grew up tough, no one will mess with me. When asked if she could recall the events on 05/27/2024 with Resident #2. Resident #1 stated, no, no I don't (do not) really remember. Interview on 05/31/2024 at 11:17 a.m., LVN A confirmed she documented both Resident #1 and Resident #2's progress notes of the events on 05/27/2024 at 15:45 15:45 (03:45 p.m.). LVN A stated Resident #1 threw the cup at Resident #2, LVN A stated she completed an incident report, and she reported the incident to ADM. LVN A stated she was aware of reporting all ANE (Abuse, Neglect, and Exploitation) allegations and incidents to the ADM, LVN A stated that, if we don't (do not) report ANE, it places residents at risk. Interview on 05/31/2024 at 11:29 a.m., DON stated she was aware of Resident #1 throwing a cup of water to Resident #2, although she was not aware of the nature, cause, or reason. DON stated, I did not know she (Resident #2) did anything in an aggressive way, it was not reported to me in that nature, I did not know the reason had been anything sexual at all. DON stated it was not reported to her as an incident that involved abuse. DON stated it was not involved in the current self-reported incident that involved Resident #1 and another resident that occurred that same day. Interview on 05/31/2024 at 11:48 a.m., ADM stated LVN A never mentioned the incident involving Resident #1 and Resident #2 to him, ADM added, I was not aware the incident was rooted in a sexual comment, and this is the first time I had heard of it. ADM stated he does not recall having discussed this in the stand up meeting the following day. ADM stated, this should have been discussed with me (ADM), and that if the incident was brought to my (ADM) attention, I would have initiated an investigation and follow the investigation procedure for the facility's ANE policy. Interview on 05/31/2024 at 12:53 p.m., Psych stated she had services with Resident #1 related to another self-reported incident on 05/27/2024, Resident #1 had not display any signs of fear, or signs of verbal or sexual abuse. Psych stated that her diagnoses and conditions do involve episodes of paranoia, Psych stated that Resident #1 had not recall any incident that involved Resident #2. Psych did reiterate that Resident #1 did have generalize paranoia that could associated with her (Resident #1's) Dementia. Psych stated based on her assessment Resident #1 did not have any negative affects from that day based on her psychological assessment. Record review of the Facility's Resident to Resident incident, no date, revealed an incident that 676267 Page 2 of 3 676267 06/05/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0610 involved Resident #1, reported by LVN A, on 05/27/2024 at 15:45 (03:45 p.m.): Level of Harm - Minimal harm or potential for actual harm Nursing description: Reported that resident had thrown a small cup of cold water on another resident. Residents Affected - Few Resident Description: Resident stated that she did throw the water on the other resident because the other resident is always talking sexual talk to her. Immediate action taken: Assessment done. Family called. Resident on 1-1 intervention, no injuries noted, and staff intervened to prevent altercation. Other resident assisted away from area staff without injuries. Record review of the Facility Abuse: Prevention of and Prohibition Against Policy, revision/review date 10/2022, revealed a policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Further review of the Facility's policy revealed: Section F. Investigation, 1. All identified events are reported to the Administrator immediately. 676267 Page 3 of 3