Coral Rehabilitation And Nursing Of Austin

Review of facility's policy titled Handwashing/Hand Hygiene revised August 2019 reflected: Policy Statement.1.

All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventingthe transmission of healthcare-associated infections.

Record review of the facility's Tracheostomy Care Policy, revised August of 2013, reflected it focused on the steps of replacing the trach and site and stoma care. It did not address physician orders or who should be providing care.This was determined to be an Immediate Jeopardy (IJ) on 08/28/2025 at 1:42 p.m.

The ADM was notified.

The ADM was provided with the IJ template on 08/28/2025 at 1:45 p.m .

The following Plan of Removal was submitted by the facility and accepted on 09/05/25 at 1:45 p.m.:Plan of Removal (POR) - F-F695 POR Accepted at - 09/05/25 at 01:45 PMImmediate JeopardyOn 08/28/2025, an abbreviated survey was re-opened at the Facility. On the same date, the surveyor provided an Immediate Jeopardy (IJ) Template notification indicating that the facility failed to meet regulatory requirements under F-F695, placing Resident #1 at risk of serious harm due to lack of appropriate tracheostomy care.The IJ was triggered due to:Absence of physician orders for trach care, suctioning, and stoma monitoring. - Resident #1 performing his own trach care without documented training, oversight, or competency validation. - Evidence of potential harm, including pneumonia diagnosis and unsafe supply reuse.Action 1: Safe Discharge and Removal of Tracheostomy CapabilitiesEffective immediately as of 09/04/2025, the facility will remove all tracheostomy clinical capabilities.

The 2 residents with tracheo[TRUNCATE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Coral Rehabilitation and Nursing of Austin

6909 Burnet LN Austin, TX 78757

SUMMARY STATEMENT OF DEFICIENCIES

Review of an in-service, dated 08/13/25 and conducted by the RDON, reflected nurses from all shifts were in-serviced on the facility policies regarding pain medication administration, medication orders and documentation, pain-clinical protocol, narcotic reconciliation, and medication ordering and inventory tracking.

Review of Licensed Nurse Competency quizzes, dated 08/13/25, reflected all nurses completed the quiz on pain management and medication administration with no concerns.

Review of physician orders for 28 residents (including Resident #1) with orders for PRN pain medication, dated 08/13/25, reflected an order for pain monitoring Q shift and PRN, using PAINAD or number scale. If pain unrelieved post pain medication - call provider immediately.

Review of Resident #1's August 2025 MAR and his narcotic count sheet, on 08/13/25, reflected he was administered Hydrocodone that day (08/13/25) at 11:49 AM.

The RDON was notified on 08/13/25 at 6:05 PM that the IJ had been removed.

While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Coral Rehabilitation and Nursing of Austin

6909 Burnet LN Austin, TX 78757

SUMMARY STATEMENT OF DEFICIENCIES

Review of text message sent to staff on 09/05/25 in mass message system reflected message that came from DON to staff Please let it be known from this moment forward that our clinical capabilities have changed, and we will no longer be accepting residents who are tracheostomy dependent.

The text reflected was sent to department heads.

Review of AdHOC QAPI for IJ F-F695 and F-F726 dated 09/04/25 reflected: Action: IJ and POR reviewed with medical director, administrator, RN consultant and DON. POR and POC will be reviewed during monthly QAPI X3 months and revised as needed, to sustain improvement.

The facility clinical capabilities were discussed, as well as recent decision to transfer all current tracheostomy patients to other facilities/safe medical facility. It was agreed upon that facility will no longer accept new tracheostomy patients for admission.The ADM was informed the Immediate Jeopardy was removed on 08/28/2025 at 4:41 p.m.

The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Coral Rehabilitation and Nursing of Austin

6909 Burnet LN Austin, TX 78757

SUMMARY STATEMENT OF DEFICIENCIES

orders for pain medication to be administered prior to wouldcare.The following information should be recorded in the resident's medical record:1.

The type of wound care given.2.

The date and time the wound care was given.3.

The position in which the resident was placed.4.

The name and title of the individual performing the wound care.5.

Any change in the resident's condition.6.

All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.7.

How the resident tolerated the procedure.8.

Any problems or complaints made by the resident related to the procedure9. If the resident refused the treatment and the reason(s) why.10.

The signature and title of the person recording the data.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Coral Rehabilitation and Nursing of Austin

6909 Burnet LN Austin, TX 78757

SUMMARY STATEMENT OF DEFICIENCIES

(15) seconds using antimicrobial or nonantimicrobialsoap and water under the following conditions:a.

Before and after direct contact with residents.b.

When hands are visibly dirty or soiled with blood or other body fluids.c.

After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin.d.

After removing gloves.e.

After handling items potentially contaminated with blood, body fluids, or secretions.4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands arenot visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all thefollowing situations:a.

Before and after direct contact with residents.b.

Before donning sterile gloves.c.

Before performing any non-surgical invasive procedures.d.

Before preparing or handling medications.e.

Before handling clean or soiled dressings, gauze pads, etc.f.

Before moving from a contaminated body site to a clean body site during resident care.g.

After contact with a resident's intact skin.h.

After handling used dressings, contaminated equipment, etc.i.

After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; andj.

After removing gloves.5.

Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or bodyfluids or other potentially infectious materials.

Record review of the facility's policy titled Personal Protective Equipment-Using Gloves, revised September 2010, reflected: PurposeTo guide the use of gloves.Objectives1. To prevent the spread of infection.Miscellaneous1.

When gloves are indicated, use disposable single-use gloves.2.

Discard used gloves into the waste receptacle inside the examination or treatment room.3.

Use sterile gloves for invasive procedures to prevent contamination of the patient, and to decrease the riskof infection when changing dressings.4.

Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providingtreatment or services to the patient and when cleaning contaminated surfaces.5.

Wash hands after removing gloves. (Note: Gloves do not replace handwashing.)When to Use Gloves1.

When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin.2.

When the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis, etc.3.

When cleaning up spills or splashes of blood or body fluids.4.

When cleaning potentially contaminated items; and5.

Whenever in doubt.Removing Gloves1.

Using one hand, pull the cuff down over the opposite hand turning the glove inside out.2.

Discard the glove into the designated waste receptacle inside the room.3.

With the ungloved hand, pull the cuff down over the opposite hand, turning the glove inside out.4.

Discard the glove into the designated waste receptacle inside the room.5.

Discard the glove package into a waste receptacle inside the room.6.

Wash hands.

Facility ID: