West Oaks Nursing And Rehabilitation Center

F-F755- The facility failed to ensure pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia.

Action: Medical Director notification

Start Date: 2/10/25

Completion Date: 2/10/25

Responsible: Executive Director

Action: Audit all admissions/readmissions from 1/23/25 to present to ensure all medications were correctly verified.

Start Date: 2/10/25

Completion Date: 2/10/25

Responsible: DON/Designee/Clinical Resource

Action: Inservice DON on admission requirements to verify orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders:

a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders.

b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders.

c. These steps will remain in the permanent admission/readmission protocol.

Start Date: 2/10/25

Completion Date: 2/10/25

Responsible: Clinical Resource

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 676095 Department of Health & Human Services Printed: 09/09/2025 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 676095 B. Wing 02/11/2025

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

West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748

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 0760 Action: Inservice Nursing and Nursing Leadership staff on admission requirements to verify orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders: Level of Harm - Immediate jeopardy to resident health or a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. safety b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting Residents Affected - Some nurse to assist in retrieving discharge summaries/orders.

c. These steps will remain in the permanent admission/readmission protocol.

Start Date: 2/10/25

Completion Date: 2/11/25

Responsible: DON/Designee

Action: Ad hoc QA1 meeting. Attendees will include ED, DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions.

Start Date: 2/10/25

Completion Date: 2/10/25

Responsible: Executive Director

Action: Admissions Coordinator inservice on notification of pharmacy consultant of all admissions/readmissions for medication review.

Start Date: 2/11/25

Completion Date: 2/11/25

Responsible: DON

Systemic Change to Prevent Re-Occurrence:

DON/Designee will ensure admitting nursing staff verify admission/readmission orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders:

d. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders.

e. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders.

f. These steps will remain in the permanent admission/readmission protocol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 676095 Department of Health & Human Services Printed: 09/09/2025 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 676095 B. Wing 02/11/2025

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

West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748

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 0760 Monitoring to Ensure Ongoing Compliance:

Level of Harm - Immediate DON/ Designee will audit order listing report daily to include admissions and readmissions. jeopardy to resident health or safety Will include trends of verification of orders upon admissions during QAPI meeting x 90 days.

Residents Affected - Some Surveyor monitored the POR on 2/11/2025 as followed:

Review of the facility's in-service training report dated 02/10/2025 and titled admission process verification of medication on admission and readmission reflected it was provided to the DON by Clinical resource.

Review of facility in-service titled notification of pharmacy consultant of all admission and readmission for medication review dated 02/11/2025 reflected in-service was provided to admission coordinator.

Review of facility in-service dated 02/10/2025 titled Admission/Verification of Meds reflected it was completed with 25 nurses. Review reflected any admission will have medication verification against discharge orders. If a resident did not bring orders, hospital needed to be called and attempts needed to be made to get orders. If unable to do so, documentation needed to be noted in the resident's charge. Notification to DON/ADON/NP was to be made to attempt to get discharge orders and staff should pass along on the 24-hour report.

Review of admission medication orders audit for admissions on 1/23/2025 included 23 residents. No discrepancies were listed.

Review of QAPI sign-in sheet dated 02/10/2025 reflected a meeting was conducted and included the ADM, DON, NP, and Medical Director.

During interviews on 02/11/2025 between 2:27 PM and 3:30 PM, with 2 RNs and 4 LVNs, it was revealed that staff received an in-service either 2/10/2025 or prior to their shift on 2/11/2025 by the DON or Clinical resource. Staff stated that the in-service included to ensure orders were received for any new admission and if the resident did not come with paperwork then the staff should try to contact the hospital and if they are unable to get through then they should notify the DON/ADON. Staff stated this information should be written

on the 24-hour report and document all that was done and who was notified in management and attempts made to get the orders. Staff stated the NP should also be called and notified that a patient was sent with no orders. Staff stated if a resident was still at the hospital at midnight then they would be considered a new admission and all orders should have been discontinued and all new orders would be put in as if they were a new patient. Staff stated that if a resident was sent out with low blood sugar, they would want to check the resident's blood sugar when they returned and may ask the NP if they wanted to initial blood sugar checks and felt that was standard nursing care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 676095 Department of Health & Human Services Printed: 09/09/2025 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 676095 B. Wing 02/11/2025

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

West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748

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 0760 During an interview on 02/11/2025 at 3:36 PM, the DON stated in-service was provided to her on 02/10/2025 by clinical resource. DON stated nurses were in-serviced prior to beginning their shift of if they were present Level of Harm - Immediate yesterday (02/10/2025). DON stated the process was updated and for any admission staff was to ensure jeopardy to resident health or they received discharge orders. If they were not received, then they should call the sending facility that safety discharged the residents. DON stated if staff could not get ahold of the facility, then it should be communicated with the DON/ADON/NP and with the oncoming shift. DON/ADON would then attempt to get Residents Affected - Some ahold of the MD to get discharge orders. DON stated if the resident was not back in the facility by midnight, then their medications should be discontinued, and the medications would have to be entered again like a new admission. DON stated that ADONs would pull an order listing from the report daily and cross reference

the information with discharge paperwork and what is in PCC. DON stated order listing report will also be discussed during QAPI and during IDT meetings.

The ED was notified on 02/11/2025 at 3:45 PM that the IJ had been removed. While the IJ was removed, the facility remained out of compliance at a level of no actual harm that was not immediate jeopardy at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 676095