Retirement And Nursing Center Austin

F-F740) on 05/08/2025 and an Ad-Hoc QAPI meeting was held on 05/08/2025 to discuss the findings.

All findings will be reported to the QAPI team for QAPI.

Expected compliance date is 05/08/2025.

The Surveyor monitored the POR on 05/10/25 as follows:

During an observation and interview on 05/10/25 at 3:39 PM, Resident #1 was observed as she sat in her wheelchair. Resident #1 was calm and had no s/sx of distress. Resident #1 stated she was fine and rolled away. CNA H stated she was assigned to Resident #1 to monitor for behaviors , for example yelling, throwing things, or being aggressive towards others. She stated there were none of those behaviors exhibited by Resident #1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 455862 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455862 B. Wing 05/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

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 0740 During interviews on 05/10/25 from 12:44 PM - 3:07 PM, staff from all shifts including the ADON, two LVNs (LVN D and LVN E), one CNA (CNA G), one MA (MA I), one SW, and the HSK Supervisor all stated they Level of Harm - Immediate were in-serviced on 05/08/25 or 05/09/25 on abuse and neglect. All staff knew to report any suspected abuse jeopardy to resident health or immediately to the ADM who was the Abuse Coordinator. All staff stated they were to report any new safety behaviors or increased number of behaviors such as hitting, kicking, cussing, or increased complaints, to the charge nurse. Staff stated if two residents were involved in an altercation, they would separate the residents Residents Affected - Some and report the incident to the nurse. The LVNs and SW stated all diagnoses were reviewed on admit and which diagnoses required psych referrals. They stated the NP was to be notified of any new or change in behaviors. The SW stated he was to follow up on all psych referrals within 2-3 days.

During an interview on 05/10/25 at 1:31 PM, the SW stated the expectation was to send psych service referrals for residents with a psychiatric diagnosis or behavior medications evaluations for residents with behaviors when admitted and as needed. He stated the expectation was to follow up on all referrals within two to three days.

During an interview on 05/10/25 at 1:40 PM, the Psych NP stated he had no recommendations for staff regarding Resident #1, who he observed was stable on 05/09/25. Staff were expected to follow the facility's policy if a resident exhibited new behaviors. Staff were expected to deescalate the resident, notify appropriate parties, and provide psych services. He stated he planned to see Resident #1 weekly for a few weeks to monitor medication effectiveness. He would reevaluate then if weekly visits were still indicated or adjust the frequency as needed.

During an interview on 05/10/25 at 3:07 PM, the ADON stated it was her expectation that psych and behavioral referrals were initiated and sent when a resident was admitted and if a change in behaviors occurred. She stated the SW was responsible to follow up on the referral status.

During a telephone interview on 05/10/25 at 3:53 PM, the RDO stated he in-serviced the ADM, DON, and ADON on 05/08/25 regarding behavioral care and services for the residents for the facility and following up

on psych referrals after sending out psych referrals.

During a telephone interview on 05/10/25 at 3:55 PM, the MD stated the DON notified him about Resident #1's incident resulting in an IJ on 05/08/25 or 05/09/25.

During an interview on 05/10/25 at 4:29 PM, the ADM stated she expected psych referrals be sent timely when a resident with a psychiatric diagnosis was admitted . She expected the SW to follow up with the referral to ensure the service was provided. She stated they had implemented audit tools and now monitored for compliance. She stated the audit tools were to monitor compliance to the facility's communication procedure for contacting physicians and confirming orders on behavioral health matters.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 455862 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455862 B. Wing 05/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

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 0740 Review of an in-service titled Behavioral Care and Services in Texas Nursing Homes, dated 05/08/25, reflected the RDO in-serviced the ADM, DON, and ADON on the policy and procedures. The outline from the Level of Harm - Immediate in-service reflected in part, Objective: Equip staff with the knowledge and skills to deliver person-centered jeopardy to resident health or behavioral care in compliance with Texas regulations and CMS guidelines. Objectives of This In-Service: By safety the end of this session, participants will be able to: Recognize common behavioral and psychological symptoms in residents. Respond effectively and compassionately to behavioral issues . Understanding Residents Affected - Some Behavioral Health in LTC Settings . Resident-Centered Behavioral Interventions . Role of the Interdisciplinary Team . Documentation Best Practices . Key Takeaways Behavioral care is part of holistic resident care. Staff training and communication are essential. Non-pharmacological approaches should be tried first. Documentation must be timely, factual, and complete. Interdisciplinary collaboration leads to better outcomes.

Review of an in-service titled Behavioral Care and Services in Texas Nursing Homes, dated 05/08/25 and 05/09/25, reflected staff, which included 1 RN, 9 LVNs, 6 MAs, and 20 CNAs, were in-serviced, in person or over the phone, by the ADM, DON, and ADON on the policy and procedures.

Review of an in-service titled Abuse/Neglect, dated 05/08/25 and 05/09/25, reflected staff , which included 1 RN, 9 LVNs, 6 MAs, 20 CNAs, 10 dietary staff, 12 housekeeping staff, 1 maintenance aide, and 7 therapy staff, were in-serviced, in person or over the phone, by the ADM, DON, and ADON on the policy and procedures.

Review of an in-service titled Ensure Proper Documentation, dated 05/08/25 and 05/09/25, reflected nursing staff, which include 1 RN and 9 LVNs, were in-serviced, in person or over the phone, by the ADM, DON, and ADON on the policy and procedures.

Review of an in-service titled New Admits, dated 05/08/25 and 05/09/25, reflected the SW and nursing staff, which included 1 RN, 9 LVNs, were in-serviced, in person or over the phone, by the ADM, DON, and ADON

on reviewing diagnoses in a timely manner and referring to psych services.

Review of the ADM's Random Selection of Staff Training Comprehension Verification reflected two staff members were verbally contacted by the ADM and verified for education on 05/09/25 and one staff member was verbally contacted b [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 455862