Inspection·July 15, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few mildly displaced distal tibial diaphyseal fracture and fibular diaphyseal fracture are visualized. The distal fibular metaphyseal irregularity is present. (both bones in the lower part of the leg had a break that was slightly out of alignment). Record review of Resident #1's social services referral provided in the provider investigation report, dated 06/11/2025 reflected During resident transfer via mechanical lift, resident's left foot was caught by the wheelchair causing fracture of her left tibia. Social Services referral initiated to check on resident's well-being and monitor for emotional distress. Record review of Resident #1's nurses notes, dated 06/11/2025 at 06:40 PM, written by RN G reflected Resident's Xray results reviewed, which revealed fracture of the left tibia and fibula.NP was notified, and an order was received to transfer the resident to the hospital for further evaluation and treatment. Record review of Resident #1's X-ray results, dated 06/11/2025, reflected AP (front to back) and lateral (side to side) views of the left ankle are submitted. The bones are osteoporotic (a condition that weakens the bones and increases the risk of fractures). The mildly displaced (not aligned) distal (part of the leg that is furthest from the body) tibial (the larger lower leg bone) diaphyseal (long portion of the bone) fracture (break) and fibular (the smaller lower leg bone) diaphyseal fracture are visualized. The distal fibular metaphyseal (the part of the bone that connects the long portion to the head of the bone) irregularity is present. Record review of Resident #1's history and physical performed by an emergency room physician in the emergency room, dated 06/11/2025, reflected .Given the patient's history of recurrent falls and underlying medical conditions, the mechanism of injury (how the injury occurred) remains unclear, though pathologic fracture (a bone fracture that occurs due to an underlying disease or weakness in the bone structure, rather than from an external force or injury) versus occult trauma (traumatic injury that is not apparent on initial evaluation) are being considered. Record review of Resident #1's physicians note, written by a doctor specializing in bones, dated 06/12/2025, reflected .Patient lives in a nursing facility and deformity (a condition in which a part of the body is distorted from the usual) was noted to the left lower extremity (leg). No noted trauma or specific event causing the injury.Additionally patient appears to be comfortable at rest and the fracture is in a position that can be splinted (a device used to support an injured body part). Record review of Resident #1's physicians note, written by a doctor specializing in hospital care, dated 06/12/2025, reflected Nursing home staff reported that they discovered the limb deformity during routine care but denied witnessing any recent falls or traumatic events that might have precipitated the injury.Given the patient's history of recurrent falls and underlying medical conditions, the mechanism of injury remains unclear, though pathologic fracture versus occult trauma are being considered. Record review of Resident #1's physicians note, written by the doctor specializing in bones, dated 06/14/2025, reflected This was a very low energy trauma (fractures that occur from minimal force) and the swelling response as expected is minimal. Record review of Resident #1's provider notes, written by NP D, dated 7/3/2025, reflected .recent hospitalization from 6/11-6/16 for acute spontaneous left tib/fib (bones of the lower leg) fracture managed conservatively with splint. An observation on 07/14/2025 at 12:50 PM, revealed Resident #1 was sitting up in a specialty wheelchair with a splint to lower left leg. Resident #1 made no attempts at communication when this investigator attempted to initiate conversation. Resident appeared clean and well-groomed with no grimacing or signs of pain. During an interview on 07/15/2025 at 09:39 AM with Resident #1's RP, she stated she was notified by someone, name unknown, that Resident #1 sustained a fracture due to osteoporosis. She stated she felt confident that Resident #1 received good care. RP stated she had not noticed any changes in mood or behaviors since the incident. She stated that Resident #1 did not talk very often, but when she did, it was only a word or two. During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 2 of 4 Printed: 05/15/2026 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Rehabilitation and Skilled Nursing C 2806 Real St Austin, TX 78722 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 - Actual harm Residents Affected - Few 07/15/2025 at 11:26 AM with LVN A, she stated she worked on 06/11/2025 when the incident with Resident #1 occurred. She stated a CNA reported to her that during the transfer of Resident #1 to her wheelchair using the mechanical lift, Resident #1's left foot got caught in the sling underneath her. LVN A stated she assessed Resident #1's left lower leg and noticed an abnormality and grimacing with movement of Resident #1's left lower leg. LVN A stated she contacted NP D and received an order for an X-ray for the left lower leg. LVN A stated she administered medication for pain to Resident #1 and notified the DON. During an interview on 07/15/2025 at 11:45 AM with NP E, who specialized in geriatric psychiatry, she stated she was notified that Resident #1 had a fracture to her left lower leg. She stated Resident #1 did[SH1] [VH2] not speak or make eye contact, but in her opinion, the resident had not had any changes in her psychosocial status due to the injury. During an interview on 07/15/2025 at 12:25 PM with NP D, she stated Resident #1 had osteoporosis. She stated she thought the fractures to Resident #1's left lower leg were pathologic. NP D stated, any wrong move or bumping it could have possibly caused it due to osteoporosis. NP D stated Resident #1 had remained at her baseline mood since the incident. During an interview on 07/15/2025 at 12:41 PM with CNA B, she stated CNA C and CNA B used the mechanical lift to transfer Resident #1 from her bed to her wheelchair. She stated when Resident #1 was in the sling in the air, she attempted to position the wheelchair under Resident #1. CNA B stated Resident #1 started to lean to the left while in the air due to Resident #1's contractures (a shortening and stiffening of muscles, tendons, skin or other tissues that limits joint movement). CNA B stated CNA C had the remote for the mechanical lift and started to lower Resident #1 into the chair prior to CNA B repositioning Resident #1's legs. CNA B stated Resident #1's legs were trapped under herself in the chair when that happened. CNA B stated Resident #1 did not yell out or show signs of pain during the transfer. She stated Resident #1 was lifted back up and repositioned. CNA B stated when she repositioned Resident #1, Resident #1's left ankle felt loose and Resident #1 grimaced in pain. CNA B stated she reported the incident to LVN A and the DON. During an interview on 07/15/2025 at 02:05 PM with RN F, she stated she was working the day of the incident with Resident #1. She stated she was instructed to perform a skin assessment on Resident #1 after the incident. RN F stated Resident #1 had no swelling or redness to her left leg. RN F stated Resident #1 would grimace indicating pain with movement of her left lower leg. Attempted a phone interview on 07/15/2025 at 04:07 PM, voicemail was left without a return phone call with RN G. Attempted a phone interview on 07/15/2025 at 04:13 PM, voicemail was left without a return phone call with CNA C. During an interview on 07/15/2025 at 04:54 PM with the DON, she stated she was notified that during a transfer, two CNAs noticed Resident #1's ankle was loose, and Resident #1 was grimacing in pain. The DON stated she instructed LVN A to notify NP D, administer pain medication and immobilize Resident #1's leg. The DON stated she was not informed, during her investigation of the incident, of Resident #1's foot being trapped under her in the wheelchair. The DON stated Resident #1 had remained at her baseline since the incident. She stated CNA B and CNA C performed proficiency check offs after the incident on the same day and passed. The DON stated in-services for contractures and osteoporosis were started that same day. During an interview on 07/15/2025 at 05:26 PM with the ADMIN, he stated he was notified on 06/11/2025, Resident #1 was complaining of pain to the left lower leg. He stated an X-ray was performed and a fracture was found. He stated after discussion with NP D, Resident #1 was sent to the emergency room. The ADMIN stated he was not informed of Resident #1's leg being trapped under her during the transfer. He stated the CNAs were required to perform a re-creation of the event and that detail was not mentioned. He stated that was concerning to him. Record review of facility in-service, dated 5/18/2025, revealed policy titled, Incidents and Accidents, dated 08/15/2022, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455599 If continuation sheet Page 3 of 4 Printed: 05/15/2026 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 455599 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Rehabilitation and Skilled Nursing C 2806 Real St Austin, TX 78722 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reflected: Policy: It is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Definitions:Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Policy Explanation:.4. The following incidents/accidents require an incident/accident report but are not limited to:. Entrapment Equipment Malfunctions. Observed accidents/incidents. Resident injuries due to staff handling.11. The nurse will enter the incident/accident information into the appropriate form/system within 8 hours of occurrence and will document all pertinent information. Record review of facility in-service, dated 06/11/2025, revealed facility assessment titled Mechanical Lift Skill Assessment. Steps listed in assessment included 13.Push gently on knees as resident is being lowered into chair to correct position and maintain balance. Lower resident slowly. Record review of facility in-service, dated 06/11/2025, revealed contents .Osteoporosis in the Elderly; Common but not a natural part of aging. Attached in-service revealed .Large gaps form in the framework ad structure of your bones, causing them to weaken and become prone to fractures. Record review of facility in-service, dated 06/16/2025, revealed topic Safe Handling and Care for Osteoporotic (Residents with a diagnosis of osteoporosis) and Atrophied (Residents with chronic weakness) Residents. Summary of training revealed *Definition of osteoporosis and muscle atrophy *Safe handling during transfers, bed mobility and peri care of high risk residents *Reviewed specific case of resident with fracture of unknown origin, discussed post surgery precautions. No attachment of discussed material noted. Event ID: Facility ID: 455599 If continuation sheet Page 4 of 4