Gracy Woods Nursing Center
Gracy Woods Nursing Center in Austin, TX — inspection on November 24, 2025.
Found 2 citations. 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
Review of Resident#1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 09, indicating moderate cognitive impairment.
During an interview on 11/07/2025 at the DON stated the facility was aware of Resident #1's right humerus fracture due to a fall on 10/16/2025.
The DON stated the X-ray was completed on 10/17/2025 on Resident #1's right arm and was positive for a fracture.
The DON stated Resident #1 was on hospice services and Resident #1's RP had declined aggressive treatment to the right humerus fracture.
The DON stated Resident #1's right fracture should have been care planned to enable staff to know what interventions to provide for Resident #1.
The DON stated the MDS nurse was responsible to update Resident #1's care plan to reflect right humerus fracture with interventions.
During an interview on 11/07/2025 at 12:40 pm the MDS Nurse stated she was responsible for completing and updating comprehensive care plan and MDS assessment.
The MDS Nurse stated the floor nurses were responsible for doing the acute care plan and they should have done an acute care plan for Resident #'s fracture.
The MDS Nurse stated an acute care plan was for something that happened to the resident right away, and examples like falls, fractures and infections, interventions were listed right away.
The MDS Nurse stated comprehensive care plans were done whenever there was a resident's assessment, generally quarterly and annually.
The MDS nurse stated the Administrator had just asked her to update Resident #1's comprehensive care plan to include risk for fall and fracture.
The MDS Nurse later stated care plans were updated for significant changes and fracture was considered a significant change.
The MDS Nurse stated, I agree with you. {Resident #1's] comprehensive care plan should have been updated to reflect fracture of her right humerus, but we have 14 days to update the comprehensive care plan for significant change. On 11/07/2025 at about 2:12 pm a request for acute care plans from the DON was made and there was no acute care plan for Resident #1 regarding the fracture of the right humerus.
Review of the facility's policy revised December 2016 titled Care Plans, Comprehensive Person-Center reflected: Policy Statement: A comprehensive, person-center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Policy Interpretation and Implementation: The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representatives, develops and implements comprehensive, person-centered care plan for each resident.
The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The Interdisciplinary Team must review and update the care plan:--when there has been a significant change in the residents' condition.--when the desire outcome is not met.--when the resident has been readmitted to the facility from a hospital stay; and --at least quarterly, in conjunction with the required quarterly MDS assessment.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Gracy Woods Nursing Center
12021 Metric Blvd Austin, TX 78758
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited Gracy Woods Nursing Center in Austin, TX for a deficiency under regulatory tag F-F0728 during a complaint investigation conducted on 2025-11-24.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of Gracy Woods Nursing Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.