Health inspection·November 24, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plan. The facility failed to develop Resident #1's comprehensive care plan to address all Resident #1's care needs. Resident #1's comprehensive care plan did not address the need for pain medication / management, risks for pressure ulcer development, assistance needed for ADL care, incontinence to bowel and bladder, medications Resident #1 was taking to manage disease processes, Hospice care, reason for oxygen therapy, DNR status, fall risk, elopement risks. This deficient practice could place residents at risk for not receiving necessary care and services. Findings included:Review of Resident #1's face sheet printed [DATE] reflected a [AGE] year-old male who was admitted on [DATE]and readmission of [DATE] with the following dx: Chronic Obstructive Pulmonary Disease ( is a condition caused by damage to the airways or other parts of the lung), Type 2 Diabetes Mellitus without complication (happens when the body cannot use insulin correctly and sugar builds up in the blood) , Pneumonia ( an infection in one or both of your lungs. It causes the air sacs of your lungs to fill up with fluids and pus), Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause), bipolar disorder ( is a mental health condition that causes extreme mood swings), Depression (also known as Depressive Disorder, is a common mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. It is different from regular mood changes), chronic kidney disease (is characterized by the presence of kidney damage. It is a stat of progressive loss of kidney function), Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms (refers to the non-malignant growth or hyperplasia of prostate tissue and a common cause of lower urinary tract symptoms in older men), Low back pain, Jaw pain, Age related decline, Asthma (a chronic lung disease affecting people of all ages. It is caused by inflammation and muscle tightening around the airway which makes it harder to breathe.). Review of Resident#1's Significant change MDS assessment dated [DATE] reflected a BIMS score of 11, indicating moderate cognitive impairment. *Section H-Bladder and Bowel reflected Resident #1 was occasionally incontinent to bladder and frequently incontinent to bowels. *Section I- Active Diagnoses reflected the following diagnoses: Bipolar Disorder, Depression, Respiratory failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus without complication, Pneumonia, Essential (Primary) Hypertension, chronic kidney disease, Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms, Low back pain, Jaw pain, Age related decline. *Section J-Health Conditions reflected Resident #1 received scheduled pain medication and PRN pain medication. Section-J also reflected Resident #1 pain frequency was frequently at a numeric rating of 7 on the scale 0-10 with 10 being the highest. *Section-M-Skin Condition reflected Resident #1 was at risk of developing pressure ulcers and Page 1 of 4 455799 455799 11/24/2025 Austin Wellness & Rehabilitation 11406 Rustic Rock Drive Austin, TX 78750

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pressure reducing device for bed was needed. *Section N-Medication reflected Resident #1 was taking the following medication: antipsychotic, antianxiety, antidepressant, opioid, antiplatelet, anticonvulsant. *Section O-Special Treatments reflected Resident #1 was on oxygen therapy and on Hospice care. Review of Resident #1's comprehensive care plan initiated [DATE] reflected only 2 care areas were addressed: The resident has Pneumonia. Azithromycin ordered and the resident has a behavior problem r/t smoking while oxygen is flowing. Further review revealed Resident #1's comprehensive care plan did not address the need for: *pain medication / management, *risks for pressure ulcer development, *assistance needed for ADL care, *incontinence to bowel and bladder,* medications Resident #1 was taking to manage disease processes, *Hospice care, *reason for oxygen therapy, *DNR status, *fall risk, and *elopement risks. Review of Resident #1's clinical assessments reflected the following:*Fall Risks evaluation completed [DATE] reflected a score of 15 indicating high fall risk.*Elopement Risks evaluation completed [DATE] reflected a score of 9 indicating imminent risk for elopement. Review of Resident #1's physician orders reflected the following orders: *Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 vial inhale orally every 6 hours for wheezing, shortness of breath given while awake dated [DATE].*DILTIAZEM 24HR ER (CD) 240MG CAP ER 24H Give 1 tablet by mouth one time a day for blood pressure dated [DATE] *Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 2 capsules by mouth one time a day for benign prostatic hyperplasia dated [DATE].*Mirtazapine Tablet 7.5 MG Give 7.5 mg by mouth at bedtime for appetite dated [DATE] *Montelukast Sodium Tablet 10 MG Give 10 mg by mouth in the morning for Asthma dated [DATE] *Nicotine Transdermal Patch 24 Hour (Nicotine) Apply 14 mg transdermally one time a day for tobacco cessation apply every morning dated [DATE] *traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 4 hours as needed for painOxygen at 3-4 l/m via nasal canula every shift related to CHRONIC RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA (occurs when oxygen is insufficient at the tissue level to maintain adequate homeostasis) OR HYPERCAPNIA (when you have too much carbon dioxide in your blood) dated [DATE]*predniSONE Oral Tablet 20 MG (Prednisone) Give 1 tablet orally one time a day for allergic reaction dated [DATE] *Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth at bedtime for insomnia dated [DATE] *OXcarbazepine ER Oral Tablet Extended Release 24 Hour 150 MG (Oxcarbazepine) Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER, UNSPECIFIED dated [DATE] *QUEtiapine Fumarate Tablet 100 MG Give 1 tablet by mouth two times a day related to BIPOLAR DISORDER, UNSPECIFIED dated [DATE] *Admit pt. to hospice Dx: COPD dated [DATE] *DNRCC (DNR Comfort Care)-dated [DATE]. Review of Resident #1's progress notes dated [DATE] at 09:45 p.m., written by LVN A reflected Resident #1 had expired on hospice services. During an interview on [DATE] at about 11:33 a.m., the ADON stated the MDS nurse was responsible for developing and updating comprehensive care plan. The ADON stated she had never done any updates on care plans. The ADON stated sometimes the DON made adjustments and update care plans when there was a change in condition. During a telephone interview on [DATE] at 12:15 p.m., the MDS Nurse stated he had worked part-time at the facility for about a year as the MDS Nurse. The MDS Nurse stated he was responsible for care plans and MDS assessments. The MDS Nurse stated MDS assessments were done every 90 days, and care plan should be updated after each MDS assessment whenever there were changes. The MDS Nurse stated the DON, ADON and floor Nurses could also update the care plan wherever there were changes in the Resident's care, not just the MDS Nurse. The MDS Nurse stated it was important to update the care plan to reflect the care that the resident was receiving. He stated residents would be impacted if the care plan was not updated. The MDS Nurse stated if a resident signs a DNR, the social worker could update the care plan. The MDS Nurse stated if a Resident code status change from full code to DNR and he was not aware, whoever changed the 455799 Page 2 of 4 455799 11/24/2025 Austin Wellness & Rehabilitation 11406 Rustic Rock Drive Austin, TX 78750

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some code status could update the care to reflect it. The MDS Nurse stated he was aware Resident #1 was placed on hospice care, and his code status had changed, and it should have been care planned. The MDS Nurse stated Resident #1 diagnoses for which he was being treated should have been care planned. The MDS Nurse reviewed Resident #1's only comprehensive care plan and stated he did not know why Resident #1 comprehensive care plan had only two (2) care areas (Pneumonia and smoking with Oxygen). During an interview on [DATE] at 1:17 pm the Social Worker stated she has never updated care plan. The Social Worker stated If a resident was not on hospice, she would help with the DNR documents and upload the document into the Resident's electronic records and alert the MDS nurse. The Social Worker stated Resident #1 hospice handled the DNR process. The Social Worker stated DNR should be care plan because that was what decided the proper procedure the facility should go through keeping in mind Resident's preferences. During an interview on [DATE] at 1:30 pm the DON stated baseline was due within 24 hours and Comprehensive care plans should be developed within the first week of admission and periodically. The DON stated he sometimes made adjustments and updates to like care plan when there were changes like a resident starting an antibiotic. The DON stated he usually reviews the dashboard for medication related changes, if there was a risk management issue such as falls. The DON stated it was important to update a care plan because care plans should reflect the residents' care needs. The DON stated he expected care plan to be updated when the MDS was done. The DON stated, if a resident was DNR, it should be reflected in the care plan. The DON stated the floor nurses should be updating the care plan for DNR and Hospice care. The DON stated a lot of times the nurses let him know if a Resident's code status had changed. The DON stated, he would look into Resident #1's care plan, he did not know Resident #1's care plan was not fully developed. The DON stated, ultimately, there was a negative outcome if a resident's care plan was not fully developed, the care plan should reflect what care was being provided or should be provided. During an interview on [DATE] at 2:16 p.m., the Administrator stated he had to review the care plan policy, look at protocols and know the timeline for care plan development. The Administrator stated he was aware that everything that a resident needed should be reflected in their care plan, it gave the story of the resident. Review of facility's policy revised [DATE], titled Care Planning reflected: Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA (Omnibus Budget Reconciliation Act-requires that each state establishes a pre-admission assessment program for any nursing home facility participating in Medicare and Medical Assistance Program) and MDS guidelines.II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/NDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases. Procedure:VIII. A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative.B. Changes may be made to the Comprehensive Care 455799 Page 3 of 4 455799 11/24/2025 Austin Wellness & Rehabilitation 11406 Rustic Rock Drive Austin, TX 78750

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan.IX. Each resident's Comprehensive Care Plan will describe the following:A. Services that are to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being.B. Any services that would be required but are not provided due to the residents' exercise of rights, which includes the right to refuse treatment.C. Any specialized services including rehabilitative serviceD. The residents' goals for admission and desired outcomes. X. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including comprehensive and quarterly review assessments.XI. The Comprehensive Care Plan must be prepared by the IDT team. 455799 Page 4 of 4