Querencia At Barton Creek

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

signed acknowledgement of education. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 9/3/2025, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Regional Director of Clinical Services, RN, [NAME] President of Health Services Operations, Executive Director, Regional [NAME] President of Operations, and Chief Clinical Officer to

review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Starting on 9/4/2025 the Director of Nursing or designee will monitor compliance daily (Monday through Friday) and Charge Nurse (Saturday and Sunday) by monitoring residents with falls for appropriate care plan revisions post fall. Care plan updates will be noted in the residents Electronic Health Record with an IDT note.

Starting on 9/4/2025 the Director of Therapy and other therapists will notify the DON, ADON, MDS Coordinator and Administrator. An email was sent the Therapy Director and therapist outlining this procedure. The Therapist acknowledged receipt and understanding with a return email. The MDS Coordinator or his designee will update the resident's care plan. Staff will be educated to review each resident's electronic are plan at the beginning of their shift. Staff will verbalize comprehension and signed acknowledgement of education. Starting on 9/4/25 the Director of Nursing or designee will monitor compliance during the weekly QOC Meeting. Results of the audit will be reported to the QAPI committee.

The Administrator/designee will monitor compliance by completing an audit of five (5) residents care plans per week for four (4) weeks. This was initiated on 9/4/2025. Documentation of this audit will be made on the post fall audit form. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Regional Director Health Services will provide oversight of the Administrator to ensure that the items on the plan of removal are reviewed and completed. 09/05/2025 4:20 PM DON, Discharge MDS 9/52025; prior to this one, ARD 8/24/2025 admission 5 day; 8/18/2025 Entry MDS/Accepted and completed; 8/24/2025 Admission/Medicare - 5 Day, In Progress; 9/5/2025 Discharge Return Anticipated in Progress. The Surveyor monitored the POR from 09/04/2025 - 09/05/2025 as followed: Record review of the facility's ADHOC meeting agenda, dated 09/03/2025, reflected ADM, DON, MD, and RDHS were in attendance. Record review of Resident #1's EMR and care plan, dated 05/23/2022 with revision on 09/04/2025 reflected review of interventions post fall and functional performance measures.

Care plan updated to

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Querencia at Barton Creek

2500 Barton Creek Blvd Austin, TX 78735

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was having pain or unable to bear weight.The CNA had transferred resident during shift, so I did not think there was a problem. I did not officially conduct skin assessment or ROM evaluation on resident on Sunday.

RN A also added that she worked the following day, Monday 2 PM - 10 PM shift and she was notified before dinner that Resident #1 was unable to transfer or get out of bed. She did notify the NP following this information and the NP informed her that he was aware and had placed order for STAT x-ray. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 CNA E statement captured, I received report from CNA A.she did not say anything about the resident [Resident #1] having pain or issues with transferring. When I went to change her on my first rounds, I noticed that she did not seem comfortable due to her facial grimacing. I informed

the nurse about the pain. On my second rounds with her [Resident #1] I felt she seemed like she was in more pain, so I moved her more gently and again I informed the nurse [RN B]. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 RN B statement captured, I was the RN on the 10-6 shift on Sunday August 3rd.On my initial assessment I did not note any indicators of pain with Resident #1. Late in my shift the CNA informed me that the resident looked uncomfortable while being changed. I administered PRN Tylenol for pain. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 CNA I statement captured, I worked as a CNA on Monday the 6a-2p shift with [Resident #1]. I did not get report from the 10p-6a shift.I arrived to the floor so I was unaware of the fall on the previous day.I noticed something was off when I went to get her out of bed that morning and she was unable to bear weight.I did not notice any visual or verbal signs of pain so I thought maybe she was just stiff from the night sleep. I noted that when I was assisting her with breakfast she was not eating well, and food was dropping out of her mouth. This was not unusual for her, but I did ask the other team members at the table if they felt there was something wrong

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Querencia at Barton Creek

2500 Barton Creek Blvd Austin, TX 78735

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

ensure they are following care plan. Failure to follow according to plan of care will result in disciplinary action and may result in potential harm to the resident. Additionally, failure to follow plan of care is considered neglect. Team members are allowed to use more assistance but never less. Notify on-call nurse manager immediately if you see someone was not care planned or needing updates to the electronic care plan. It is a requirement to use gait belt for x1-x2 assist for transfers/ambulation due to safety reasons. This was determined to be an Immediate Jeopardy (IJ) on 09/03/2025 at 7:17 PM. The ADM was notified. The ADM was provided with the IJ template on 09/03/2025 at 7:17 PM. The following Plan of Removal submitted by the facility was accepted on 09/05/2025 at 10:08 AM: On 9/3/25 Resident #1 assessed by RN for change in condition and acute pain. There were no new orders obtained. Results of the assessment were documented in the resident's Electronic Health Record (EHR). On 9/4/25 the affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. On 9/3/2025 all current residents were assessed by RN for change in condition and acute pain, no negative findings noted. Results of the assessment were documented in the resident's Electronic Health Record (EHR). The Medical Director was notified - no new orders were obtained. CNA A is no longer employed at

the facility as of 8/7/2025. On 9/3/25 Director of Nursing/Designee completed 1:1 education with CNA C on

the use of gait belt during ambulation with a resident who requires assistance with ambulation. CNA C performed return demonstration, verbalized understanding and signed acknowledgement of training. On 9/3/25 an audit of all resident rooms was conducted by the Executive Director to ensure that each room had one gait belt per resident hanging on the bathroom door. Additional gait belts can be located within Central Supply. The Central Supply Clerk is re

Event ID:

Facility ID:

If continuation sheet