Health inspection·July 23, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 6 residents observed for a clean environment. The facility failed to ensure Resident #1 had a homelike environment by not repairing the ceiling in his room in a timely manner. The deficient practice could place resident at risk of a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet dated 07/23/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses that included Fracture of T11-T12 Vertebra (compression fractures of small bones forming the backbone), Dependence on Renal Dialysis (the need for dialysis treatment to replace the function of the kidneys), Heart Failure (congestive heart failure, is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's need), Embolism And Thrombosis of Deep Veins of Right Upper (a condition where a blood clot forms in one or more of the deep veins in the body, typically in the legs), Anxiety Disorder (group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS of 15, which indicated he was cognitively intact. Record review of Resident #1's Care Plan dated 06/26/2025 reflected Resident #1 is independent and is to be offered assistance as needed and verbal encouragement as needed with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs while encouraging independence. The goals were for Resident #1 to maintain current level of function with assistance in his daily living care needs. During an interview on 07/23/2025 at 11:27 AM with Resident #1, he stated he was in the hospital from [DATE] to 06/30/2025 and returned back to the facility the beginning of July 2025. Resident #1 stated the facility staff, in which due to time he doesn't remember who he spoke with, advised him that the facility was going to patch his ceiling, and it still hasn't been patched. Resident #1 stated it's the facilities responsibility to fix the ceiling above his bed since he is paying for the room. Resident #1 stated he is frustrated that he is paying for the room this whole time and the facility hasn't addressed fixing the ceiling issue. Resident #1 stated the ceiling hasn't leaked on since 07/04/2025 when it rained as the leak was fixed, but the facility still hasn't repaired the rest of the ceiling such as, patching the drywall and repainting it. Resident #1 stated the ceiling didn't leak on him directly but there was a bin in his room to catch leaking water. Resident #1 stated the ceiling is what he sees when he lays down and it affects his quality of life and diminishes his wellbeing. Resident #1 stated he is upset that it hasn't been fixed and makes him agitated. Resident #1 stated he advised facility staff members, but the facility staff will deny knowing anything about it, and for it to still not be fixed makes him feel like he Page 1 of 3 455862 455862 07/23/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is being ignored. Resident #1 stated it is 07/23/2025 in which the facility got a new Administrator since the ceiling issue and still hasn't been repaired. Observation on 07/23/2025 at 11:30 AM, of Resident #1's room revealed the ceiling above his bed needed to be repaired, the . drywall above Resident #1's bed needed to be patched and repainted from what appeared to be from water damage. During an interview on 07/23/2025 at 12:55 AM, Maintenance Manager B, stated the facility roof on the outside of Resident #1's room was repaired for a small leak. Maintenance Manager B stated Resident #1's ceiling in the room is in the process of being repaired, he does not know why it was not fully repaired besides just the leak and was waiting for a maintenance work order to be placed by the Administrator, he said there was a new Administrator, the previous Administrator did not send him a maintenance work order. Maintenance Manager B stated to be in charge of repairs for the facility. During an interview on 07/23/2025 at 12:55 PM, the Administrator stated that Resident #1's room ceiling was not in the Maintenance Repair Logs in which she wasn't aware of the ceiling damage, nor did she know why it wasn't in the maintenance logs, she advised it to be repaired immediately as of today. During an interview on 07/23/2025 at 3:08 PM, CNA D said she had been trained in maintaining the facility environment in which it was the Maintenance Managers responsibility, but all nursing staff are to advise Maintenance for repairs needed. CNA D stated she was not aware Resident #1's ceiling needed to be repaired nor how long it had been damaged and in need of repair. CNA D stated Resident #1's quality of life can be affected if the ceiling needs to be repaired as it was not homelike. During an interview on 07/23/2025 at 3:38 PM, the DON said she had been trained in maintaining the facility environment, it needs to be maintained in a way that is a homelike environment for the residents since they reside here at the facility. The DON stated maintenance is to maintain all repairs and keep logs of hem. The DON stated it is the nursing staff responsibility to advise maintenance of any repairs in the facility and residents rooms. The DON stated she was not aware of Resident #1's ceiling;. The DON stated her expectations for maintaining homelike environment and any repairs needed such as, a leak in the ceiling or it needing to be patched as well as repainted to be done in a timely manner. The DON stated resident's quality of life can be affected if their ceiling in the room has damage and is in need of repair. During an interview on 07/23/2025 at 4:02 PM, the Administrator stated she had been trained in maintaining the facility environment like homelike environment and repairs needed in the facility for residents. The Administrator stated the Maintenance Manager is responsible for maintaining the facility environmental repairs and resident room repairs is the Maintenance Manager, all staff, and herself as the Administrator. The Administrator stated she was not aware of Resident #1's ceiling needing to be repaired nor how long it has been like that. The Administrator stated she saw the ceiling damage today 07/23/2025 when the State Investigator advised of the issue. The Administrator stated expectations for the facility is to stay in compliance in which they will be doing rounds in the facility and resident's rooms to identify any problems to get them fixed right away. The Administrator stated resident's quality of life can be affected if there is any damage in the room that needs to be repaired and is not completed in a timely manner. The Administrator stated she spoke with Resident #1 about moving rooms today and per his rights the Resident wants to remain in his room in which they are immediately going to repair the ceiling as of today. Record review of the facility in-services from May 2025 to July 2025 reflected no in-service trainings were completed regarding maintaining a homelike environment for resident's rooms. Record review of facility Maintenance Repair Logs reflected for the months of May 2025 to July 2025 had not repaired Resident #1 ceiling. Record review of email notification sent 07/23/2025 at 2:12 PM reflected, the Administrator stated she is emailing to inform Investigator in which the facility got approval today, 07/23/2025 to fix 455862 Page 2 of 3 455862 07/23/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1's roof (referring to ceiling). Record review of facility Quality of Life Homelike Environment Policy dated in 2009 reflected: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Record review of facility Maintenance Services Policy dated in 2001 reflected: Maintenance service shall be provided to all areas of the building, grounds, and equipment.1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. Maintaining the building in good repair and free from hazards.c. Maintaining the fire alarm system and emergency generator system in good working order.d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.e. Maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order.f. Establishing priorities in providing repair service.g. Maintaining the paging system in good working order.h. Maintaining the grounds, sidewalks, parking lots, etc., in good order.i. Providing routinely scheduled maintenance service to all areas.j. Others that may become necessary or appropriate.3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.4. A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents.5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule.6. Changes in maintenance schedules must be approved by the Maintenance Director.7. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments.8. The Maintenance Director is responsible for maintaining the following records/ reports.a. Inspection of building;b. Work order requests;c. Maintenance schedules;d. Authorized vendor listing; ande. Warranties and guarantees.9. Records shall be maintained in the Maintenance Director's office.10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. 455862 Page 3 of 3