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Complaint Investigation

Gracy Woods Nursing Center

September 13, 2025 · Austin, TX · 12021 Metric Blvd.
Citations 1
Beds 118
Provider ID 675918
Healthcare Facility
Gracy Woods Nursing Center
Austin, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Gracy Woods Nursing Center in Austin, TX — inspection on September 13, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

policy and did not make any revisions to the policy.

During an interview with the MD on 09/13/2025 at 2:19pm revealed that the administrator did discuss the finding and ensured continuation and participation of all practitioners with resident elopement risk.

Record Review revealed that the RDO re-educated the ADM with CN present on 09/12/2025.

The CN educated the DON on 09/12/2025.

Record review of Wandering and Elopements, policy Interpretation and Implementation In-service and Elopement Drill revealed that the DON educated staff and conducted an elopement drill with 39 of 90 staff.

Record review revealed that wander guard monitoring checklist has been completed for all shifts starting Sept. 1, 2025.

Record review of Elopement Evaluation Observation In-service Training dated 09/12/2025 revealed 16 of 34 Licensed Nurses were in-serviced on completing the elopement assessments.

Record review of elopement risk assessments revealed 93 0f 93 residents had elopement risks assessments completed.

Six residents identified as elopement risk. 6 of 6 residents' elopement risk assessment, care plan and MDS match.

Record review revealed some PRN staff have been educated.

Record review of AMA dated 09/12/2025 revealed the resident refused to sign.

Record review revealed that the medical director was called by the ADM on 09/12/2025 at 1:14pm

Record review revealed that a QAPI meeting was held on 9/11/2025. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified.

While the IJ was removed on 09/13/2025 at 3:00 p.m., the facility remained out of compliance at a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Austin, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Gracy Woods Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.