Austinwoods Rehab Health Care

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure Resident #85's pain was timely and appropriately addressed. This affected one resident (Resident #85) of four residents observed for timely and appropriate medication administration. The facility census was 83.

Inspectors wroteBased on record reviews, observations, interviews and review of the facility policy, the facility failed to ensure a medication error rate of less than five percent (%) during medication administration on 11/17/25 with four errors of 25 medication administration opportunities resulted in a 16% medication error rate. This affected two residents (Residents #85 and #86) of four residents observed during medication administration. The facility census was 83.

Inspectors wroteBased on record reviews, observations, interviews, review of facility policies, and review of manufacturer instructions for the facility's blood glucose meter, the facility failed to ensure the blood glucose meter was properly cleaned after use with Resident #86. This affected one (Resident#86) and had the potential to affect three additional (Residents #70 #73, and #81) identified by the facility as having blood sugar level checked with a glucometer. In addition, the facility did not ensure enhanced barrier precautions (EBP) were maintained during medication administration through an enteral feeding tube, affecting Resident #67. The facility identified nine residents who had enteral feeding tubes (Residents #6, #26, #45, #64, #66, #67, #69, #77, and #83). The facility census was 83.

Inspectors wroteBased on record review, observation, interview, review of Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to ensure staff performed hand hygiene to prevent possible cross contamination of germs during Resident #1's wound care and Resident #29's incontinence care. This affected one resident (#1) out of two residents reviewed for wound care and one resident (#29) out of three residents reviewed for incontinence care. The facility census was 89.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure resident #22 had a physician's order for oxygen use. This affected one resident (#22) of four residents reviewed for oxygen therapy. The facility identified 15 residents (#4, #16, #23, #30, #44, #52, #65, #70, #131, #284, #285, #289, #290, #291, and #294) that required oxygen. The facility census was 89.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure nasal sprays for Resident #41, who did not have an order to self-administer medications, were not left at the bedside. In addition, the nasal sprays left at the bedside were discontinued by the physician. This affected one resident (#41) of three residents reviewed for medication administration. The facility census was 89.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to obtain physician ordered laboratory testing for Resident #283. This affected one resident (#283) of five residents reviewed for unnecessary medications. The facility census was 89.

Inspectors wroteBased on observation, interview and Centers for Disease Control and Prevention guidelines the facility failed to ensure staff performed hand hygiene to prevent possible cross contamination of germs during Resident #1's wound care and Resident #29's incontinence care. This affected one out of three residents reviewed for incontinence care. The facility census was 89.

Inspectors wroteBased on medical record review, hospital record review, facility policy review and interview, the facility failed to provide adequate two-person assistance with bed mobility for Resident #36 as assessed/planned resulting in an injury. Actual harm occurred on 10/05/24 when Resident #36 sustained a fractured hip when one staff member (State Tested Nursing Assistant, (STNA) #110) was providing personal care for Resident #36. The resident had been assessed/planned to require two staff members for bed mobility prior to the incident. During care, the resident complained of extreme pain when the STNA lifted the left side of her body. On 10/07/24, the resident was transferred to the hospital for follow-up care. An x-ray obtained on 10/07/24 identified the fracture which the facility determined was caused by the single person bed mobility procedures with STNA #110 on 10/05/24. [...]

Inspectors wroteBased on observation, medical record review, facility policy review and interview, the facility failed to develop and implement an effective and individualized pressure ulcer prevention program to prevent the worsening of a pressure ulcer to the coccyx for Resident #37. Actual harm occurred on 05/01/24 when the facility Wound Nurse (WN) #318 identified Resident #37, who was at risk for pressure ulcer development and dependent on staff for turning and repositioning, had an unstageable (full thickness loss of tissue completely covered by dead tissue) pressure ulcer to the coccyx. The resident had been admitted to the facility on [DATE] with a Stage I (skin intact and redness to skin over a bony prominence) pressure ulcer to the coccyx. [...]

Inspectors wroteBased on medical record review, review or residents' rights and interview, the facility failed to ensure they honored a resident's right to choose their plan of treatment. This affected one (Resident #88) of three residents reviewed for change in condition. The facility census was 81.

Inspectors wroteBased on medical record review, review of a laboratory agreement, and interview, the facility failed to obtain laboratory tests in a timely manner. This affected one (Resident #88) of three residents reviewed for change in status. The facility census was 81.

Inspectors wroteBased on medical record review, review of job responsibilities and interview, the facility failed to ensure nurse practitioners provided visit notes in a timely manner and dated notes in a consistent manner to permit the determination of when the visit was made. This affected one (Resident #88) of three residents reviewed for change in condition. The facility census was 81.

Inspectors wroteBased on observation, medical record review, policy reviews and interview, the facility failed to implement Enhanced Barrier Precautions while providing wound care and incontinence care for Resident #37, and failed to appropriately use Personal Protective Equipment (PPE) while caring for Resident #44. This affected two residents (#37 and #44) out of three residents reviewed for infection control. The facility census was 81.

Inspectors wroteBased on resident interview, medical record review, staff interview and facility policy review the facility failed to ensure residents were provided showers as per their preference. This affected one (Resident #49) of three residents reviewed for showers. The facility census was 86.

Inspectors wroteBased on record review and interview the facility failed to ensure the code status in the hard chart/medical record matched the electronic medical record for two (Resident's #13 and #24) of 24 resident records reviewed. The facility census was 79. Finding Include: 1. Review of the medical record for Resident #13 revealed an admission date of 08/21/15. Diagnoses included disorder of circulatory system, heart failure, and chronic pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had intact cognition. Review of the physician orders for August 2022 identified orders for Do Not Resuscitate Comfort Care- Arrest (DNRCC-A) dated 08/07/22. Review of Resident #13's electronic chart revealed the code status matched the physician order. Review of Resident #13's hard chart on 08/23/22 at 10:14 A.M. [...]