Coral Rehabilitation and Nursing of Austin

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to ensure that :There is a system in place by which the staff know the residents who are capable of signing themselves out and safely leave the facility unsupervised. Implementation of interventions immediately to prevent residents leaving the facility without prior education on the signing in and out, upon the completion of the new admission and elopement assessment. The front door is secured when a receptionist is not present. This failure could place the residents with exit seeking behaviors at risk for injury or death.

Inspectors wroteBased on interview and record review, the facility failed to provide specialized habilitation services and failed to obtain specialized durable medical equipment for one (Resident #1) of three residents reviewed for PASRR (Preadmission Screening Resident Review) services. The facility failed to request a customized wheelchair within 20 business days after the IDT meeting for Resident #1. This failure could put residents at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and records review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for one (Resident #2) of three residents reviewed for pressure ulcer in that: The facility failed to obtain order for Resident #2's wound vac (a specialized medical device used to accelerate the healing of large, deep, or difficult-to-heal wounds) when she was re-admitted to the facility on [DATE]. Resident #2 did not have dressing change with the wound vac for four days, from 04/08/2026 to 04/12/2026 until she was transferred to the local hospital for fever of 103. This deficient practice placed Resident at risk for worsening pressure ulcers, decreased quality of care, infection and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts to resolve grievances for 1 of 1 resident council meeting reviewed for grievances. The facility failed to provide a written response to the Resident Council addressing the grievances reported from their meetings for February 2026 and March 2026. These failures could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. The findings Included:Record review of Resident Council minutes for February 2026 and March 2026 reflected repeat residents' concerns to include: the importance of staff introducing themselves and call light response times. During an interview on 04/02/2026 at 11:54 AM, Director of Special projects revealed grievances allowed for resident concerns to be addressed. [...]

Inspectors wroteBased on interview and records review, the facility failed to allow residents to manage his or her financial affairs for 3 of 7 residents (Resident #1, Resident #2 and Resident #3) reviewed. 1. The facility failed to ensure Resident #1, #2, and #3 whose funds are managed by the facility had ready access to his or her funds upon request in a timely manner, including non-business days, Saturday, and Sundays. 2. The facility failed to provide balances to Residents #1, #2, and #3 who received Medicaid benefits.3. The facility did not have a trust fund policy. This failure could place residents whose funds were managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure a quarterly trust fund statement was provided to 3 of 7 residents (Resident #1, Resident #2 and Resident #3) reviewed for personal funds. The facility failed to provide quarterly statements to Residents #1, #2, and #3 who had trust funds with the facility. This failure had the potential to affect residents who had a trust fund account managed by the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 2 of 7 residents (Resident #1 and #3) reviewed for grievances. The facility failed to ensure a grievance was completed for Resident #3 that did not receive their money in a timely manner when they asked to receive their money from their respective trust funds. The facility failed to ensure grievances from Resident Council meetings (to include Resident #1) were given to the Grievance Official (Quality Assurance Director). This failure could place residents at risk for not having their grievances resolved.

Inspectors wroteBased on record review and interview the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility reviewed for RN coverage in March 2026. The facility failed to have the services of an RN on 03/01/2026, 03/05/2026, 03/28/2026, and 03/29/2026. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility failed to employ a full-time social worker from January 2026 to April 2026, the facility was licensed for 157 beds. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 4 residents (Resident #2 and Resident #4) reviewed for care plans. 1. The facility failed to ensure Resident #2's care plan was revised to reflect the resident's fall on 1/22/26. 2. The facility failed to ensure Resident #4's care plan was revised to reflect the resident's aggression toward another resident on 2/13/26. These failures could place residents at risk of their current needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 12 residents (Resident #8) reviewed for neglect. The facility neglected to follow its process for elopement when they failed to monitor an exit door when the alarm was bypassed by staff during EMS entry/exit. Resident #8 eloped from the facility's Unit 3 vicinity hall 100 door between 7:15 p.m. and 7:30 p.m. on 12/5/25 and was found by law enforcement on a bus on 12/9/25. Resident #8 had severe cognitive impairment, impaired safety awareness, and a history of strokes. An IJ (Immediate Jeopardy) was identified on 12/07/25. The IJ template was provided to the facility on [DATE] at 2:45 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to extend to the resident representative the right to make decisions on behalf of the resident for 1 of 12 residents (Resident #8) reviewed for resident representative rights. Resident #8 eloped from the facility on 12/5/25 between the period 7:15 p.m. to 7:30 p.m. and the Guardian was not contacted immediately. This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 6 (Resident #1) residents reviewed, in that: There was no physician order for the use of the continuous positive airway pressure machine for Resident #1. This failure could result in inadequate care due to incomplete and inaccurate medical records.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident's representative when there is an accident involving the resident which results in injury and had the potential for requiring physician intervention for 1 (Resident #86) of 5 residents reviewed for falls. The facility failed to notify Resident #86's physician and FM that he had a fall on [DATE]. He was found unresponsive at the facility around 6:30 AM on [DATE] and subsequently passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:23 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right to be free from neglect for 1 (Resident #86) of 5 residents reviewed for resident neglect. The facility failed to ensure Resident #86 was free from neglect when nursing staff failed to conduct ongoing neuro checks and monitor for delayed complications after an unwitnessed fall with head injury that occurred on [DATE]; and document in the residents' chart changes in condition, notify the family and physician, and follow facility fall protocol per policy and residents person centered care plan. He was found unresponsive around 6:30 AM on [DATE] and subsequently passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 p.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #86 and Resident #33) reviewed for care plans. 1. The facility failed to implement Resident #86's care plan intervention which included follow fall protocol (which consisted of ongoing neuro checks, post fall assessments, and notifying RP and physician) after Resident #86 sustained an unwitnessed fall with a head injury on [DATE]. Resident #86 was found unresponsive around 6:30 AM on [DATE] and subsequently passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure that all nursing staff possess the competencies, and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 1 (Resident #86) of 5 residents reviewed. - The facility failed to ensure nursing staff were competent to conduct ongoing neuro checks, notify the family, and notify the physician after Resident #86 had an unwitnessed fall and hit his head on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control. The facility failed to keep an effective pest control program to ensure the residents' rooms including bathrooms, halls, and recreation room (where resident activities are held) were free of roaches, flies, spiders, and water bugs. This failure could place residents at risk for reduced quality of life and poor sanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 3 (Resident #1, Resident #17, and Resident #70) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure the MDS dated [DATE] was updated to reflect an active pressure wound for Resident #1. The facility failed to ensure the MDS dated [DATE] was updated to reflect an active pressure wound for Resident #17. The facility failed to ensure the MDS dated [DATE] was updated to reflect an active pressure wound for Resident #70. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who was unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 3 of 8 residents (Resident #9, Resident #18, and Resident #44) reviewed for Activities of Daily Living's. The facility failed to ensure Resident #9 and Resident #44's fingernails were trimmed. The facility failed to ensure Resident #18's facial hair was shaved. This failure was evident and could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 (Medication storage room- Hall 100, Medication storage room-Hall 200) of 2 Medication storage rooms and 1 (Nurses' med cart - Hall 100) of 4 medication carts reviewed for medication storage. The facility failed to ensure :1. The medications stored in the hall 100 and hall 200 medication storage rooms were not expired .2. The content in a medication bottle in the hall 200 medication storage room was the medication labelled on the bottle.3. No mobile phone was stored in the hall 100 nurses' medication cart.4. Food items were not stored in the medication refrigerator in the hall 100 medication storage room. [...]

Inspectors wroteBased on observation, interviews, and record reviews; the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of open stored perishable food products. 2. The facility failed to properly label and date food products in one of two freezers. 3. The facility failed to properly label and date food products in two of two kitchen pantries. 4. The facility failed to properly label and date food products throughout one of one kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 (Resident #18) of 8 residents reviewed for sanitary rooms. The facility failed to ensure Resident #18's floor was not sticky on 09/09/25 at 12:14 PM and 3:30 PM. This failure could place residents at risk for reduced quality of life and poor sanitary environment.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #33) of 5 residents reviewed for PASRR. The facility failed to perform a new PASRR level 1 assessment on Resident #33 for the diagnosis of bipolar disorder. This failure could place residents at risk of not receiving needed services and support. Findings Included:Record review of Resident #33's face sheet dated 09/10/25 revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's baseline Care Plan to include the minimum healthcare information necessary to properly care for a resident for 1 of 6 residents (Resident #55) whose records were reviewed for baseline care plans. The facility failed to ensure Resident #55 has a baseline care plan for the Jackson Pratt drain (a medical device used to remove excess fluid from a surgical site or wound, preventing swelling and promoting healing) and skin care at the incision site, since his admission on [DATE]. This failure could place residents at risk of not receiving required care.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 resident (Resident #55) of 5 residents reviewed for treatments. The facility failed to ensure Resident #55 received a continuous quality Jackson Pratt drain care and skin care at the incision site, since his admission on [DATE]. This failure could lead to outcomes, including pancreatic fistulas (an abnormal opening or tunnel that forms in the pancreas and allows pancreatic fluid to leak into surrounding tissues or organs), infections and hemorrhage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #70) of 6 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure LVN I and CNA J changed dirty gloves when handling clean items and sanitized the surfaces while providing peri care and wound care to Resident #70. This failure could place residents at risk for healthcare associated cross-contamination and infections. Findings Included:Record review of Resident #70's face sheet dated 09/10/25 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to have evidence that all alleged violations are thoroughly investigated for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to initiate and complete a thorough investigation of Resident #1's injury of unknown origin. Staff observed Resident #1 had discoloration to his buttocks area on 09/10/25. Staff confirmed Resident #1's discoloration was an acute (sudden) femur (thigh) fracture on 09/11/25. An IJ was identified on 09/18/25. The IJ template was provided to the facility on [DATE] at 7:10 p.m. While the IJ was removed on 09/21/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the resident environment remains free of accident hazards and each resident receives adequate supervision for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to monitor and supervise Resident #1, who was cognitively impaired and a fall risk. Resident #1 complained of pain and had discoloration to his buttocks area on 09/10/25. Resident #1 sustained an acute (sudden) femoral (thigh) fracture and was sent to the hospital for surgery on 09/11/25. An IJ was identified on 09/18/25. The IJ template was provided to the facility on [DATE] at 7:10 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report Resident #1's injury of unknown origin to the SSA. Staff observed Resident #1 had discoloration to his buttocks area on 09/10/25. Staff confirmed Resident #1's discoloration was an acute (sudden) femur (thigh) fracture on 09/11/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for tracheal care.1. The facility failed to have orders in place to provide care to Resident #1's tracheostomy (a hole in front of the neck and into the windpipe) since he was admitted to the facility on [DATE].2. The facility failed to provide regular tracheostomy care to Resident #1, as the nurses did not feel comfortable, leaving the resident to provide his own tracheostomy care since admission on [DATE]. Resident #1 was sent to the hospital on [DATE] and diagnosed with pneumonia. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for pain. The facility failed to: - Order Resident #1's Hydrocodone before it ran out, causing him to be excruciating pain for two days (08/10/25 - 08/12/25), resulting in him being sent to the ER.- Properly document the ordered PRN Hydrocodone administered to Resident #1 as his August 2025 MAR did not match the narc count sheet for his PRN Hydrocodone.- Assess Resident #1 for the effectiveness of his PRN Hydrocodone (as ordered) after it was administered during August 2025. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one of three Residents (Resident #4) reviewed for competent nursing staff. LVN E failed to provide trach care and suctioning to Resident #4 according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 08/28/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and ensured the written notice included a statement of the resident's appeal rights, which included the name, address (mailing and email), and telephone number of the entity which received such requests and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request for 2 of 3 residents (Resident #2 and Resident #3) reviewed for discharge planning. 1. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 2 of 4 residents (Resident #2, and Resident #3) reviewed for pressure ulcers. The facility failed to follow the physician's orders for providing wound care for Resident #2 and Resident #3, on a regular basis. This failure could place residents at risk of worsening their wounds. Findings Include: 1. Record review of Resident #2's face sheet, dated 09/05/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acute congestive heart failure ( sudden and severe failure of the heart) , obesity, asthma, acute respiratory failure and edema (Swelling). [...]

Inspectors wroteBased on observation, interview and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in one of three residents (Resident #4) review for infection control. 1. LVN E failed to perform hand hygiene before and after glove changes while performing trach care and suctioning on Resident #4. 2. LVN E failed to follow sterile technique while Suctioning Resident 42. These deficient practices could place residents at risks for infection, respiratory distress, hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided with care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure Resident #1 had an order indicating an oxygen flow rate via his trach collar while on his room concentrator and portable oxygen unit as needed for hypoxia from 06/06/25 through 08/15/25. These failures could place residents at risk for symptoms and manifestations of hypoxia, the decreased perfusion of oxygen to the tissues and a decreased quality of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 6 residents observed for a clean environment. The facility failed to ensure Resident #1 had a homelike environment by not repairing the ceiling in his room in a timely manner. The deficient practice could place resident at risk of a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #4, and Resident #8) of ten residents reviewed for quality of care. The facility failed to: 1. Ensure Resident #1 had orders to manage or maintain his colostomy (an opening in the large intestine) since admission date 05/23/2025. 2. Ensure Residents #4 and #8 had a physician's order for the days they received their dialysis treatment. Residents #4 and #8 both went to dialysis on Mondays, Wednesdays, and Fridays. This deficient practice could place residents at risk of not receiving adequate care, harm, or injuries.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 7 residents (Resident #2, 3, 4 & 5) reviewed for infection control. The facility failed to have signage on resident doors that reflected PPE was required for high contact care for Residents #2, 3, 4 and 5 on 06/05/2025. The facility failed on 06/05/2025 when staff failed to wear PPE while providing high contact resident care (dressing, bathing, transfers, wound care, device) to Residents #3 and 4. The facility failed when ADON did not change gloves or perform hand hygiene while providing wound care for Resident #4's left heel on 06/05/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #3) of 4 residents review for catheter care. The facility failed when RN A did not re-insert Resident #3's foley catheter (a medical device that helps drain urine from the bladder) when it came out on 06/05/2025 sometime around 7:00 am until 3:25 pm. Resident #3 voiced multiple times how she would prefer her catheter to be in because she could not tell when she was voiding on herself which made her uncomfortable. This deficient practice could place residents at risk for infection, sepsis (is a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death.) and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications);- for one (Resident #1) of four residents reviewed for quality of care. The facility failed notify Resident #1's NP or RP when he was experiencing a change in condition/decline for an unknown length of time when he stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to ensure staff did not address (and/or document) a change in condition for an unknown length of time when Resident #1 stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. He was admitted to the hospital on [DATE] and was diagnosed with possible aspiration pneumonia (a lung infection that occurs when food or liquid is inhaled into the lungs, leading to inflammation and infection), a UTI, and a left femur fracture. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/25 at 4:27 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 7 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8) of 7 residents reviewed for a clean and homelike environment. 1. The facility failed to maintain temperatures between 71 degrees and 81 degrees Fahrenheit on the 100 and 200 halls on 05/20/2025. This failure could place residents at risk of living in an uncomfortable and unsafe environment, diminished quality of life and experience symptoms related to heat exacerbation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 5 residents (Resident #1) reviewed for prevention and treatment of mental and substance use disorders. -The facility failed to ensure behavioral health interventions were implemented for Resident#1, who was admitted with a diagnosis of bi-polar disorder and had a history of being aggressive to residents and staff, after physician orders for psychiatry evaluation and management were received on 02/24/25 and again on 03/08/25. [...]

Inspectors wroteBased on observations, interviews , and record reviews, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately to the State Survey Agency (HHSC), but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, for 2 of 5 residents (Resident #3 and Resident #4) reviewed for abuse. The facility failed to report to the State Survey Agency (HHSC) an incident of alleged abuse/neglect when Resident #4 grabbed Resident #3's walker and pushed it causing Resident #3 to fall and sustain a large skin tear on his forearm on 04/05/25. This failure could place residents at risk for harm to include physical abuse, a diminished quality of life, and psychosocial harm.

Inspectors wroteBased on interviews and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #1) of 4 residents reviewed for physician notification, in that: The facility failed to notify Resident #1's physician or nurse practice of missed medications due to the resident being out on pass from the facility on 04/01/2025, 04/02/2025, 04/03/2025, 04/05/2025, 04/06/2025 04/07/2025 and 04/08/2025. This failure could result in decreased continuity of care, and a delay in needed treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for 1 of 4 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's aspirin, doxepin, divalproex, haloperidol, folic acid, multivitamin and metoprolol were administered according to the physician's orders. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed promptly to assist residents in obtaining routine dental services to meet the needs of 3 (Resident #2, Resident #3, and Resident #4) of 4 residents reviewed for dental services. 1. The facility failed to provide or obtain dental services for Resident #2, Resident #3, and Resident #4. 2. The facility failed to promptly provide dental services for Resident #3 due for denture placement and document why the referral did not occur within three days. This failure could place residents at risk of oral complications, pain, difficulty eating and diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified for one (Resident #1) of four residents reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect her falls on 02/11/2025, 03/09/2025 and 03/23/2025. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 5 residents (Resident # 1 and #2) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1 and #2's wheelchair was maintained. These failures could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for two (Resident #1 and Resident #2) of five residents reviewed for resident rights. The facility failed to: 1.) Ensure CNA C was not on his phone during peri care with Resident #1 on 02/12/25. 2.) Ensure Resident #2 was not ambulating through the facility without a dignity (privacy) bag covering his foley catheter bag on 02/25/25. These deficient practices could place residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #1) of three residents reviewed for enteral nutrition. The facility failed to keep Resident #1's head of her bed elevated at least 30 degrees while receiving enteral nutrition through a g-tube for approximately an hour on 02/17/25. She was found to have difficulty breathing and foam/secretions in and around her mouth. This failure could place residents at risk of tube malfunction, aspiration, and death.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 4 of 4 residents (Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for baseline care plan. The facility failed to initiate a baseline care plan within 48 hours of the admission date for Resident #3, Resident #4, Resident #5, and Resident #6. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs were met.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 3 residents (Resident #3, Resident #5, and Resident #6) reviewed for care plans. The facility failed to develop a person-centered care plan for Resident #3, Resident #5, and Resident #6. This deficient practice could affect residents and place them at risk for not having their needs and preferences met.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with respect and dignity for 1 of 7 (Resident #2) residents reviewed for dignity in that: The facility failed to ensure staff closed Resident #2's door and pull the privacy curtain closed while changing the resident. This failure could affect residents and place them at risk for psychosocial harm due to a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 7 residents reviewed for ADL's. The facility failed to ensure Resident #1 had clean sheets on her bed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #2) of five residents reviewed for nutrition. The facility failed to ensure Resident #2 maintained acceptable parameters of nutritional status as demonstrated by Resident #2 experiencing a 25.38% weight loss in six months. He had an active decline in his weight from 05/01/24 - 11/01/24. This failure could place residents at risk for decreased nutritional status, decline in health, malnutrition, or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to assess complete a skin assess when Resident #1 acquired a skin tear on 11/19/24. Four treatments were missed and he developed an infection requiring antibiotics. These failures placed residents at risk of improper wound management, the development of new skin integrity issues, deterioration in existing skin integrity, infection, and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice before discharge was provided to 1 (Resident #1) of 3 residents reviewed for transfer/discharge, in that: Resident #1 and/or their representative were not provided a written notice of discharge prior to being discharged out of the facility. The Ombudsman was not provided a copy of the notice. This failure had the potential to affect the resident by not having the knowledge of why the resident was discharged , emotional distress, decline in quality of life, disregarding the residents rights, how to appeal the discharge, and the right to appeal the discharge.

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights, in that: The facility failed to provide documentation that Resident #1 received sufficient preparation and orientation when she was discharged home, to ensure a safe discharge. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse and for one (Resident #11) of twenty residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement and utilize the following two facility abuse and neglect policies; abuse investigation and reporting policy and abuse prevention and reporting policy when; 1) they did not report an allegation of rape reported to two State of Texas and the facility administrator reported by Resident #11. 2) Immediately notify police of the alleged allegations and take action to protect Resident #11 from possible physical and emotional abuse. By failing to implement these policies, the facility failed to; [...]

Inspectors wroteBased on interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one of twenty residents (Resident #11) reviewed for abuse and neglect, in that The facility had failed to conduct an investigation when there was an allegation of rape from Resident #11. The resident had approximately 3 other allegations of rape that the facility could not provide supporting documentation that those allegations were indeed investigated. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/12/24 at 11:33 AM. While the IJ was removed on 08/13/24 at 5:30 PM, the facility remained at a level of actual no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 4 of 5 residents (Resident ' s #81, #15, #44, and #7) reviewed for resident rights. The facility failed to ensure Resident #81 ' s call light was within reach on 08/06/24 and 08/07/24. The facility failed to ensure Resident #15 ' s call light was in reach on 08/07/24. The facility failed to ensure Resident #44 ' s call light was in reach on 08/07/24 and 08/08/24. The facility failed to ensure Resident #7's call light was within reach on 08/11/24. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 8 residents (Resident #13, Resident#17, and Resident #63) reviewed for resident rights. The facility failed to ensure Resident #13, Resident#17, and Resident #63 to provide a safe bedroom free from obstacles with closets accessible to the resident . This failure could place residents at risk for falls and rooms being overheated from the air conditioner being turned off.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made for 1 of 20 residents screened for abuse (Resident #11). The facility failed to immediately report to the State Agency (within 2 hours) an allegation of sexual abuse made by Resident #11 on 03/11/2024 and 08/09/2024, and additionally when staff had knowledge of allegations of rape as reported to the PMHNP as collateral information on 07/12/2024 and 08/02/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 3 of 15 residents (Resident #79, Resident #66, and #68) reviewed for ADLs. The facility failed to ensure Residents #79 was provided assistance with ADLS and eating as documented in his plan of care which made him feel frustrated and that nobody cared about him. The facility failed to provide regular showers to Residents #66 and #68 in accordance with their plan of care. This failure could place residents at risk of weight loss, malnutrition, loss of dignity, and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 (Resident #81) of 5 residents reviewed for dignity. The facility failed to ensure Residents #81's urinary bedside drainage bag was placed in a privacy bag on 08/06/24 and 08/07/24. This failure could have compromised residents' dignity for those who require tubing and a urinary bedside drainage bag.

Inspectors wroteResident #57 Based on interviews and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 2 of 8 residents (Resident #57 and Resident #61) reviewed for notification of changes. A. The facility failed to ensure the physician was notified of Resident #57 refusing his medication Mirtazapine (a medication for depression) and Risperidone (a medication used to control his schizophrenia). B. The facility failed to ensure the physician was notified of Resident #61 was refusing his medications Coreg (a medication used to treat his heart failure). This failure could place residents at risk of not receiving appropriate medical treatments, which could result in severe illness or hospitalization.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 20 residents (Resident #74) reviewed for freedom from physical restraints. The facility failed to ensure Resident #74 was free from restraint when Resident #74 was left sitting in a Geriatric (elderly) chair with the feeding tray fully attached throughout the day. This failure could unnecessarily inhibit the resident's freedom of movement or activity and could affect residents by placing them at risk of physical harm, pain, mental anguish, emotional distress, and serious harm.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #61) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #61 right to refuse medication and refusals of medications prior to survey. 2. The facility failed to care plan Resident #61 wishes to self-administer vitamin supplements prior to survey. 3. The facility failed to accuracly care plan Resident #68's diagnoses of malnutrition (protein or calorie) by care planning for a recommended diet for weight reduction and not weight gain. This failure placed residents at risk of their needs having gone unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 (Resident #5) of 8 residents reviewed for respiratory care. The facility failed to ensure Resident #5's Oxygen tubing was changed every seven days and there was water filled in the humidifier daily. This failure could place all residents who use respiratory equipment at risk for respiratory complications including infections. Record review of Resident #5 undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had a diagnosis of Chronic Obstructive Pulmonary Disease (a disorder affecting the lungs making it difficult to breath), Hypertension (elevated blood Pressure), and Heart Failure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' drug regimen were adequately monitored and free from unnecessary drugs for 1 (Resident #54) of 8 residents reviewed for pharmacy services. The facility failed to monitor Resident #54 for side effects/adverse reactions (bruising bleeding,dark black bowel movements) or the use of Eliquis (an anticoagulant medication- blood thinner) prior to survey. These failures could place residents at risk of bruising, and bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5% for 3 of 25 (error rate 12%) opportunities for errors during medication pass. 1)The facility failed to administer Resident # 34 his folic acid tablet during the medication administration observation. 2) The facility failed to administer Resident #76 his probiotic capsule and his men's multivitamin with minerals during the medication administration observation. This failure could place residents at risk of not receiving the intended therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to self-administer medications and safely store medications in room if the IDT determined that the practice was clinically appropriate for one of eight residents (Resident #61) reviewed for medication self-administration. The facility failed to assess for IDT approval for Resident #61 to self-administer his medication and did not provide a secure area in the resident's room to store the medications prior to surveyor entry. This failure could place residents at risk of consuming unsafe medications.

Inspectors wroteBased on interviews and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #68) of twenty residents reviewed for accurate clinical records, in that: The facility failed to ensure Resident #68's medication administration record accurately reflected the medications Resident #68 received.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #57, and Resident #61) of 8 residents reviewed for infection control. The Medications Assistant failed to preform hand hygiene before and after medication administration between Resident #57, and Resident #61 61 during the morning medication pass. These failures have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral or secondary infections and communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents/resident representatives were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for one (Resident #1) of three residents reviewed for consents. The facility failed to obtain written consent from Resident #1's Representative (RP) before administering her Ativan (for anxiety) and Depakote (for behavioral issues). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions.

Inspectors wroteBased on observation and interview, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a need to alter treatment significantly for one (Resident #1) of three residents reviewed for changes in treatment. The facility failed to obtain written consent from Resident #1's Representative (RP) before administering her Ativan (for anxiety) and Depakote (for behavioral issues). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 1 (Resident #1) of 4 residents review for resident assessments. The facility failed to ensure Resident #1's bruises identified on 04/26/24 were reflected in Resident #1's skin assessments. This deficient practice could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices, in that the facility did not completely and accurately document the treatment administration for 1 (Resident #1) of 3 residents reviewed for Treatment Administration Records. The facility failed to document the wound care to Resident #1, as ordered by the physician. This failure could place residents at risk of delay in wound infection and healing process. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect result in bodily injury, to other officials (including the State Agency) for 1 (Resident #5) of 10 residents reviewed for abuse, neglect, and misappropriation of property, in that: The facility failed to report to the State Survey Agency within two hours after Resident #5 alleged he was abused by Housekeeper D on 02/24/24 at 7:00 p.m. This failure could place residents at risk of feeling unsafe, injury, and revictimization by the same alleged perpetrator.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to post, in a form and manner accessible and understandable to residents and resident representatives the HHSC complaint number, at 1 of 2 nursing stations, 1 of 1 dining rooms, 1 of 1 front lobby areas, and 1 of 1 activity rooms observed, in that: The facility failed to post the HHSC complaint number and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of property in the facility. This failure placed residents at risk of being unaware of who and how to contact the State Survey Agency and their right to file a complaint with the State Survey Agency concerning any suspected violation of state or federal regulation.

Inspectors wrotePOST IDR Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of five residents reviewed for quality of care, in that: The facility failed to provide wound treatments according to physician orders and to assess and obtain treatment orders for new or worsening wounds from 09/01/23 to 10/02/23. Resident #1 and Resident #2's wounds deteriorated during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/20/23 at 4:29 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new pressure ulcers from developing for one (Resident #3) of five residents reviewed for pressure injuries, in that: The facility failed to provide wound treatments according to physician orders and to assess and obtain treatment orders for new or worsening wounds from 09/01/23 to 10/02/23. Resident #3's wounds deteriorated during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/20/23 at 4:29 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #15, Resident #51, and Resident #71) of 3 residents reviewed for accidents and supervision. Resident #71 offered illegal substances to Residents #15 and #51 to smoke in the facility. The facility failed to ensure the resident was assessed upon admission to the facility to determine if she was safe to smoke independently. The resident was found smoking in the building on two separate occasions, smoking outside the building unsupervised on one occasion and after a search of her room, smoking and drug paraphernalia were found. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program in that: 1. Flies were observed in all areas of the facility. These failures placed residents at risk for disease and infection and a diminished quality of life. Findings Include: Observation on 06/26/2023 at 12:45 PM one to five flies at each of the seven tables in the dining area. Observed three residents at one table who actively waived flies away and heard the residents discuss that the flies landed on their food. Observed on 06/26/2023 at 2:00 PM a fly in rooms [ROOM NUMBERS]. Observed on 0/26/2023 between 2:09 PM and 2:26 PM in the dining room three flies on an empty table, a fly in the air, a fly on an incomplete puzzle, 2 additional flies in the air, and seven flies on an empty table. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, or injuries of unknown origin were reported immediately but not later than 24 hours after the allegation was made for one of three residents (Resident #15, Resident #51, and Resident #71) reviewed. The facility failed to report to the State survey agency that Resident #71 was smoking in her room, in the facility, a prohibited smoking area outside the facility and was in possession of illegal drugs and paraphernalia in her and offered the drugs to Resident #15 and Resident #51. This deficient practice placed residents at risk for harm.