Health inspection·September 5, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and ensured the written notice included a statement of the resident's appeal rights, which included the name, address (mailing and email), and telephone number of the entity which received such requests and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request for 2 of 3 residents (Resident #2 and Resident #3) reviewed for discharge planning. 1. The facility failed to notify Resident #2 and Resident #2's RP of Resident #2's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understood, and at least 30 days before Resident #2 was discharged from the facility on 09/04/25, in a facility-initiated discharge to another skilled nursing facility (SNF B). -. The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #2 was discharged from the facility on 09/04/25. 3. The facility failed to notify Resident #3 and Resident #3's RP of a reason for her discharge from the facility, an effective discharge date , a location to which she would discharge to after the hospital since not being allowed back to SNF A, her right to appeal, and the facility Ombudsman's contact information in writing, in a language and manner he understood and at least 30 days or as soon as practicable before she was required to discharge from the facility. -. The facility failed to send a copy of the Resident #3's notice of discharge to the facility's Ombudsman. These failures could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. Findings include: 1. Record review of Resident #2's face sheet, dated 09/05/25, reflected a [AGE] year-old male who was admitted to the facility 05/06/25. Resident #2 had diagnoses which included tracheostomy status, cerebral infarction (stroke), and acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). Resident #2 discharged from the facility on 09/04/25 to home: resident's home. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score was not assessed due to the resident rarely/never understood. The MDS included an active diagnosis of tracheostomy status. Record review of Resident #2's care plan, dated 01/14/25, reflected a focus of [Resident #2] has tracheostomy related to impaired breathing mechanics. Record review of Resident #2's progress note reflected a social services note, dated 09/04/25, SW spoke with POA about resident transfer to another facility. POA was ok with transfer and suggests that, if possible, can we look into a facility in [specified location]. Record review of Resident 2's progress notes reflected a nursing note, dated 09/04/25, resident discharge to [SNF B] via wheelchair with the assistance of transporter and nurse. Personal belongings and medications transfer with resident upon discharge. Review of Resident #2's EMR reflected no discharge notice. In an interview on 09/05/25 at 10:30 AM Page 1 of 30 455862 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with Resident #2's family, she stated she received a call from the SW on 09/04/25 advising her Resident #2 would be discharged and transferred to [SNF C]. Resident # 2's family stated it was very abrupt and asked for a second to research the facility. She stated she requested information about other facilities in the area but she was told by the SW Resident #2 would be transferred out to [SNF C] regardless and she [Resident #2's family] could decide to move him again if she did not like [SNF C] once Resident #2 was there. She stated the SW told her it had to occur immediately because they did not have the proper staff to care for Resident #2 there at [SNF A]. During the interview with the State Surveyor, Resident #2's family stated she was about to contact [SNF A] to find out when the discharge for Resident #2 would occur, and was informed by the State Surveyor Resident #2 was already gone and discharged as of 09/04/25 per the EMR to [SNF B]. Resident #2's family stated she was shocked and was not informed of when the discharge would occur, did not know Resident #2 had already been discharged the previous day, was told he would be going to [SNF C] and never spoken to about [SNF B] and was not given enough notice to select a facility of her choosing or even options. Resident #2's family stated she would be following up with the facility [SNF A] to get confirmation of where Resident #2 actually was and why she was not informed of the changes. 2. Record review of Resident #3's face sheet, dated 09/05/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included hemiplegia (paralysis that affects only one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stoke) affecting left non-dominant side, cognitive communication deficit, and acute respiratory failure. Resident #3 was discharged to an acute care hospital on [DATE]. Record review of Resident #3's discharge return anticipated MDS (which was the most recent MDS), dated [DATE], reflected the BIMS was not assessed. Record review of Resident #3's care plan, last revised 08/28/25, reflected a focus [Resident #3] has altered respiratory status related to trach requiring oxygen. Record review of Resident #3's progress notes reflected a note, dated 09/04/25, which indicated Resident #3 was sent to an acute care hospital, abnormal x-ray (left hemithorax opacification) NP notified, resident to be sent for evaluation and treatment acute CT scan, resident to be sent to acute care hospital per family request. Review of Resident #3's EMR reflected no discharge notice. Record review of Resident #3's progress note reflected a discharge note, entered by the ADM on 09/05/25, administrator spoke via phone to [SNF B] staff, admissions nurse for [SNF B]. He has been in contact with [acute care hospital] to let them know that his facility has reviewed clinicals for [Resident #3] and are willing to accept her upon discharge from [acute care hospital], administrator requested [SNF B] staff follow up with this facility if there are further updates. In an interview on 09/05/25 at 10:55 AM with Resident #3's family, she stated she received a call from the SW on 09/04/25 and she was told by the SW Resident #3 would not be allowed back to the facility [SNF A] after her hospital stay and it was due to not having the staff that was able to care for Resident #3. Resident #3's family stated she asked where Resident #3 was supposed to go, the SW advised her they would begin to send out referrals to other SNFs and when he heard back, he would let her know. Resident #3's family stated she was not aware information was sent to SNF B or that Resident #3 would be discharged there after her hospital stay instead of back to SNF A. Resident #3's family stated all of Resident #3's belongings were still at SNF A and nothing was planned to pick them up because she was unaware of this happening due to no prior notice. In an interview on 09/05/25 at 01:27 PM with the SW, he stated he was contacted by the ADM advising they had to discharge Residents #2 and #3; the discharge was occurring due to nursing staff lacking the competencies to care for their tracheostomy. The SW stated if residents were non interviewable like Resident #2 and Resident #3, staff were to consult with the residents POA or RP in the event 455862 Page 2 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of a discharge. The SW stated in a proper discharge advance notice was provided to the resident or their representative and included information on where they were going and who was going to be the point of contact. The SW stated in a facility initiated discharge the notice of discharge also needed to contain information to the ombudsman, and the residents appeal rights. He stated the discharge was also not to occur until the 30th day after the notice was provided unless appealed. The SW also stated the resident was to be provided a list of facilities and choices of where to go, and the resident or their representative was to be provided a reason for the discharge. The SW stated he was not aware of Resident #2 going to SNF B instead of SNF C where he was supposed to go. The SW stated in his communication with the ADM, both Resident #2 and Resident #3 were going to SNF C, which was not the case based on the notes he saw in the residents' charts. The SW stated when he saw the notes in the residents' charts for them to go to SNF C, he believed someone else in the facility contacted the families to let them know. The SW stated a notice to the ombudsman for the discharge of both Resident #2 and Resident #3 were not provided. The SW stated a negative outcome of not giving notice to the residents, or their representatives of a discharge would be they would have to be admitted back, and an appropriate discharge would have to be performed. The SW stated although notice was not provided, he considered this a safe discharge because they were in places they could receive the proper care for their tracheostomies. In an interview on 09/05/25 at 05:19 PM with the ADM, she stated in the event staff was unable to consult with the resident of a discharge they would consult with the residents RP. The ADM stated a safe discharge was any location where the residents' needs can be accommodated. The ADM stated notice was to be provided for the discharge to the resident or their representative in a facility-initiated discharge. She stated they had the right to know where they were being discharged to and why the discharge was necessary. The ADM stated she did not provide the notice to the families because she believed the SW would be contacting them to let them know the facility could no longer provide care to them due to their traches. The ADM stated she believed the discharge to Resident #2 and Resident #3 were safe because they were in places they could receive the proper care. The ADM stated she contacted the hospital where Resident #3 was and let them know they could no longer accept trach residents and Resident #3 would not be allowed back to SNF A. She stated Resident #3's family would be able to pick up her items at their convenience. She stated Resident #2 was sent to SNF B with all his belongings. The ADM stated a negative outcome of not providing notice of discharge or allowing them choices was they would not be able to actively participate in their own care. The ADM stated this could be against the residents' rights. Record review of the facility's Discharging the Resident policy, last revised December 2016, reflected:- The resident should be consulted about the discharge.- Reassure the resident that all his or her personal effects will be taken to his or her place of residence.- If discharging the resident to another long-term care facility tell the resident:a. Where the new facility is located.b. How large the facility is, what services it offers, what it looks like, etc. (if known).c. Any information you can about the facility. (Note: If you don't know, ask the supervisor about thisinformation.)d. Who will be providing the resident's care (i.e., nurses, assistants, therapists, etc.).e. That his or her family and visitors will be informed of the discharge and where the resident will beliving.f. Why the discharge is necessary (i.e., closer to home, relatives, etc.). (Note: If this information is notknown, ask the supervisor about this information.).- Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's Resident Rights Policy, last revised December 2016, reflected:- Exercise his or her rights of the facility and as a resident or citizen of the United States.- Be supported by the facility in exercising his or her rights.- Be notified of his or her 455862 Page 3 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0628 condition and any changes to condition.- Be informed of and participate in his or her care planning and treatment. - Refuse a transfer from a distinct part within the institution. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455862 Page 4 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for tracheal care.1. The facility failed to have orders in place to provide care to Resident #1's tracheostomy (a hole in front of the neck and into the windpipe) since he was admitted to the facility on [DATE].2. The facility failed to provide regular tracheostomy care to Resident #1, as the nurses did not feel comfortable, leaving the resident to provide his own tracheostomy care since admission on [DATE]. Resident #1 was sent to the hospital on [DATE] and diagnosed with pneumonia. 3. The facility failed to provide trach care and suctioning to Resident #4 according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 08/28/2025. While the IJ was removed on 09/05/2025, the facility remained at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.These failures could place residents at risk of infection, respiratory distress, pneumonia, and hospitalization.Findings include:1.Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure with hypoxia (low levels of oxygen in the body's tissues), tracheostomy status, dysphagia (difficulty swallowing), and end-stage renal disease.Record review of Resident #1's quarterly MDS assessment, dated 07/10/25, reflected a BIMS score of 14, which indicated he was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected he required tracheostomy care.Record review of Resident #1's quarterly care plan, dated 08/10/25, reflected he had a tracheostomy related to impaired breathing mechanics with an intervention of suctioning as necessary and ensuring the trach ties were secured at all times.Record review of Resident #1's physician's orders in his EMR, on 08/12/25, reflected no orders for trach care.During a telephone interview on 08/12/25 at 9:33 AM, Resident #1's RP stated the facility made him clean his own trach. She stated, the other day (unsure of date) when she visited him, he had two cannulas in a bag with water in it. She stated he had been reusing the disposable cannulas. She stated she told him he could not use the same cannula twice and was worried about his trach site getting infected.During an observation and interview on 08/12/25 at 10:20 AM, LVN B stated Resident #1 was currently at the hospital . He stated he (Resident #1) performed his own trach care because he preferred to do it himself. He stated they (nurses) just ensured he had the supplies. When asked to see trach supplies, he opened his cart and realized there were no cannulas in the cart. LVN B led the State Surveyor to the supply closet where there was a box of disposable cannulas.During an interview on 08/12/25 at 12:52 PM, Resident #1's NP stated if a resident had a trach, his expectations were there be orders in place for PRN suctioning, changing the trach on a scheduled bases, and monitoring of the stoma. He stated he was not aware Resident #1 did not have orders for trach care. He stated his expectations were that nurses provided trach care. He stated he was aware Resident #1 sometimes performed his own trach care and he told him to let the nurses do it. He stated the residents were not well-educated enough and would need training. He stated you could not reuse a disposable cannula because Disposable meant disposable. He stated there was a big risk of infection control issues or suctioning too much could also cause issues . He stated if Resident #1 could properly take care of his trach, he would be living at home. He stated he lived at the facility because he needed a higher level of care.During an interview on 08/12/25 at 2:44 PM, the RDON stated if a resident had a trach, there Residents Affected - Some 455862 Page 5 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some should be orders on suctioning, monitoring, and cleaning the site. She stated it did not meet her expectations for a resident to not have orders if they had a trach. She stated it was important to ensure they received the care they needed. She stated a negative outcome could be infection issues, death, or other safety concerns. She stated residents were not supposed to care for their own trach because that could lead to improper care and maintenance.During an observation and interview on 08/13/25 at 1:35 PM revealed Resident #1 received a dialysis treatment. He was able to communicate by the State Surveyor reading his lips. He stated he often had to tend to his stoma site and trach because the staff were not cleaning or suctioning it, and he was scared it would become infected.Observation and interview on 08/28/25 at 10:00 a.m. revealed multiple used trach inner cannulas in Resident #l's room on his bedside table. Resident #1 stated he was afraid of running out of supplies and would wash off the trach inner cannula in the sink in his bathroom. Resident #1's RP was present and stated she often had to bring supplies from home for Resident #1's trach. It was also observed, while Resident #1 was standing, he was on continuous oxygen at 4 liters, Resident #1's split gauze under his trach was scrunched up at his neck, partially covering his stoma. When Resident #1's RP tried to look at the stoma, the Resident #1 could not tolerate the process, and he began to gasp for air.During an interview on 08/29/2025 at about 10:00 a.m., Resident #1's RP stated while they were about to leave the facility on 08/28/2025 for Resident #1's GI appointment, Resident #1 stated he did not feel good. The RP stated she assessed Resident #1, and his oxygen level was in the 80s and his blood glucose was high. Resident #1's RP stated she immediately took Resident #1 to the ER where he was admitted and diagnosed with pneumonia.During an interview on 08/29/2025 at 10:12 a.m., LVN E stated nurses were responsible for performing trach care on residents. LVN E stated the RDON was responsible for training nurses on trach care. LVN E stated she felt she had the trach care training/skills to meet residents' needs, but she sometimes did not have what she needed to perform trach care . LVN E explained she felt she did not have and could not find the trach care equipment to perform trach care. LVN E stated she did not receive trach care training and proper use of trach care equipment. LVN E stated no one spoke with her about trach care when she started her shift on 08/29/2025. LVN E stated she did not receive periodic evaluations of her trach skills and knowledge from the facility. LVN E stated she felt the facility needed to reeducate nurses on trach care and said, Because nurses may forget certain steps in the procedure. If you do not work hands on, there are certain things you don't remember. Residents could be at risk of having trouble breathing, becoming confused, and becoming combative. Critical case. Has to do with the airway when it comes to the breathing and has to do with infection. Residents could acquire an infection when it comes to lack of breathing due to lack of trach care competency . During an interview on 08/29/2025 at 10:34 a.m., LVN G stated nurses were responsible for performing trach care on residents. LVN G stated she did not know who was responsible for training nurses on trach care. LVN G stated she felt she did not have the trach care training to meet residents' needs and informed the facility she did not have the trach care training upon her hire. LVN G stated she did not receive trach care training from the facility. LVN G stated no one trained her on trach care and spoke with her about trach care when she started her shift on 08/29/25. LVN G stated she needed a trach care reeducation to meet residents' needs. LVN G stated she never was asked to perform trach care. LVN G stated she had not been trained on proper use of trach care equipment. LVN G stated she also did not receive periodic evaluations of trach care. LVN G stated she knew the importance of nurses being educated and competent in trach care and said, To make sure residents are good and safe. Residents could choke or die or get an infection .During an interview on 08/29/25 at 10:55 a.m., LVN A stated he was trained on trach care 3-4 months ago. He stated he never 455862 Page 6 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some performed trach care on a resident at the facility. He stated he felt like he would need supervision to perform trach care as he had only ever performed trach care on a mannequin. He stated he had never been asked to perform trach care at the facility and had only provided residents with trach care supplies when they asked. LVN A stated although he had been trained on proper trach care and equipment, he had not received any periodic evaluations on his trach skills and knowledge. He stated he knew it was important to have trach care education because it was life threatening and residents could be at risk of airway obstruction and infection. He stated it would not be acceptable for a resident to wash their inner cannula in the sink because the water was not sterile . He stated he did not know Resident #1 was reusing his nasal cannulas and had never observed him provide his own trach care. He stated he was not sure if Resident #1 had been trained on performing his own trach care. He stated Resident #1's trach collar was always clean and he would replace the gauze when it was dirty.During an interview on 08/29/25 at 11:27 PM, the RDON stated staff were skill-checked every six months on trach care. She sated the last check-off was early June and July of 2025. She stated the RDON was responsible for skill-checking nurses on trach care and knew it was important to educate on trach care because residents could be at risk for any complication. The RDON stated she was not aware, nor did she observe Resident #1 performing his own trach care. She stated she would have expected for floor staff to observe him perform care to ensure he was doing it appropriately. She stated if Resident #1 was refusing trach care by the nurses, she would expect them to notify the provider, RP, and family of the refusals . The RDON stated she was still looking for staff competency evaluations. During an observation and interview on 08/29/25 at 2:02 PM, Resident #1 was sitting on his hospital bed in the hospital. He stated he had been doing his own trach care at the facility because he did not believe facility staff were competent to do so. He stated the facility nurses told him they did not know how to perform trach care. He stated facility staff never supervised, monitored, nor offered to supervise his own trach care. He stated he often had to use his own trach care supplies.During an interview on 08/29/25 at 2:03 PM, HN H stated Resident #1 was admitted to the hospital for fluid overload and pneumonia. She stated Resident #1 had a trach, chronic respiratory failure, and a history of pneumonia. She stated improper trach care could potentially result in pneumonia. During a telephone interview on 08/29/25 at 4:18 PM, Resident #1's NP stated if nurses were not comfortable and untrained in trach care, residents could be at risk of not receiving proper care which could develop infections, respiratory distress, and numerous other complications. He stated he was under the impression the RT was responsible for training nurses on trach care, but he had not seen the RT for quite some time. He stated he was unaware of how often the RT visited the facility .Record review of Resident #1's hospital records, dated 08/28/2025, reflected Resident #1 was checked into the hospital on [DATE] at 10:30 a.m. and reflected the following: History of Present Illness-Patient is a [AGE] year old male w/ past medical history of End-Stage Renal Disease on hemodialysis, chronic hypoxemic respiratory failure, trach dependent who presented to the emergency department with complaints of increased shortness of breath, dyspnea for the past 2 weeks. He was saturating at 74% on arrival to the emergency department. He states he has been compliant with his dialysis and was last dialyzed yesterday. He has had increased secretions during the past week. CXR showed a moderate right pleural effusion with small loculated component and diffuse patchy opacities.Assessment/Plan--Acute on Chronic Hypoxic Respiratory Failure, right pleural effusion w/ loculated component, Diffuse patchy opacities- Concern for possible pneumonia given X-ray findings.- Will initiate treatment.4. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old male with original admission date of [DATE] and readmission date of [DATE]. Resident #4 had diagnoses which included tracheostomy status (a 455862 Page 7 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some surgical procedure that creates an opening in the trachea-windpipe to allow breathing), acute and chronic Respiratory failure with hypoxia (Hypoxia is a condition in which there is an inadequate supply of oxygen to the body's tissues), Gastrostomy status (refers to the presence of a surgical opening in the stomach that allows for the insertion of a tube for feeding or other purposes), acute on chronic systolic Congestive heart failure (a condition where a sudden worsening of symptoms occurs in some who already has chronic systolic heart failure), cerebral infarction (occurs when blood flow in the brain is interrupted, leading to cell death and brain damage), and dysphagia (difficulty swallowing). Record review of Resident #4's quarterly MDS assessment, dated 08/20/2025, reflected a BIMS score of 00, which indicated severe cognitive impairment. Staff assessment reflected Resident #4 had both short-term and long-term memory problems. Section O reflected Resident #4 required Oxygen therapy, suctioning and tracheostomy care.Record review of Resident #4's care plan, initiated 01/14/2025, reflected Resident #4 had tracheostomy related to impaired breathing mechanics and was on oxygen at 4LPM, Resident #4 was NPO.Record review of Resident #4's physician orders, dated 05/08/2025, reflected: Suction as needed to maintain patency every 1 hours as needed for as needed to maintain patency of trach. Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. one time a day for Reduce risk of infection 6-inch trachRecord review of Resident #4's physician orders, dated 06/23/2025, reflected: Monitor trach for placement every shift.Record review of Resident #4's physician orders, dated 08/29/2025, reflected: Monitor trach stoma site for issues including but not limited to: S/S of infection, irritation, redness, swelling, pain, mucosal tissue issues. Notify MD or NP for any findings which are abnormal and complete progress note. every shift for tracheostomy care Notify for abnormal findings and complete progress note. Trach care daily and PRN: For disposable: (Trach Canula size 7.5) remove and dispose of inner cannula. Replace with new inner cannula, gauze, and collar. one time a day for Reduce risk of infection Inner Canula Size [NAME] 7.5Observation on 08/29/25 at 09:03 a.m. revealed LVN E collecting supplies to perform trach care on Resident #4. LVN E was observed collecting supplies from the medication cart such as trach kit and a 10cc vial of normal saline. LVN E donned an isolation gown and a clean glove without performing hand hygiene . LVN E took clean gauze wiped Resident #4's oxygen mask removing the excess secretions, then wiped Resident #4's left neck and shoulder removing excess secretions. LVN E then reached into her pants pocket with her soiled gloved hand and pulled a glove out . LVN E then removed the glove from 1 hand, reached in her pants pocket again but did not get anything. LVN E removed gloves from the other hand and walked out to the doorway to get more gloves from her medication cart, which was parked in the doorway. LVN E grabbed more gloves from her medication cart and placed gloves in her pants pocket. LVN E applied clean gloves without hand hygiene, took the yankauer (A Yankauer is a medical suction device used to remove fluids, blood, secretions, and debris from a patient's oral airway or surgical site to prevent aspiration and maintain a clear field for healthcare providers.) and inserted it into Resident #4's trach, suctioning while going in and coming out of the trach. LVN E used water which she took from a normal saline vial (10 cc), put water in a plastic cup which was not sterile to clean the yankauer. LVN E again inserted the yankauer into Resident #4's trach, with the yankauer not being sterile, and again applied suction while going in and coming out. LVN E removed soiled gloves, no hand hygiene, reached in her pants pocket for clean gloves, the nurse applied clean gloves, applied split gauze under Resident #4's trach, did not clean Resident #4's trach stoma, did not change Resident #4's trach tide even though it was saturated with secretions. LVN E did not check Resident #4's oxygen prior to trach care or suctioning or hyper-oxygenate Resident #4 during the procedure. Resident #4 was noted kicking the wall and the window each time suction was 455862 Page 8 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some applied . During an interview on 08/29/2025 at 10:12 a.m., LVN E stated nurses were responsible for performing trach care on residents. LVN E stated the RDON was responsible for training nurses on trach care. LVN E stated she felt she had the trach care training/skills to meet residents' needs, but she sometimes did not have what she needed to perform trach care. LVN E explained she felt she did not have and could not find the trach care equipment to perform trach care. LVN E stated she did not receive trach care training and proper use of trach care equipment. LVN E stated no one spoke with her about trach care when she started her shift on 08/29/2025. LVN E stated she did not receive periodic evaluations of her trach skills and knowledge from the facility. LVN E stated she felt the facility needed to reeducate nurses on trach care and said, Because nurses may forget certain steps in the procedure. If you did not work hands on, there were certain things you didn't remember. Residents could be at risk of having trouble breathing, becoming confused, and becoming combative. Critical case. Has to do with the airway when it comes to the breathing and has to do with infection. Residents could acquire an infection when it came to lack of breathing due to lack of trach care competency. LVN E stated she knew to suction a resident depending on when a resident choked on phlegm. LVN E stated she did not perform trach care for Resident #4 because she did not see the water to use . LVN E stated she observed Resident #4 had excessive secretions around his neck and shoulder. LVN E stated she used normal saline during Resident #4's trach care. LVN E stated she had to go to another unit to get the trach equipment to perform trach care because she did not see the equipment available on her unit. LVN E stated she was not familiar with Resident #4. LVN E stated the nurses needed inner cannula for emergency purposes, oxygen mask, sterile water, cannister when performing trach care.During an interview on 08/29/2025 at 10:34 a.m., LVN G stated nurses were responsible for performing trach care on residents. LVN G stated she did not know who was responsible for training nurses on trach care. LVN G stated she felt she did not have the trach care training to meet residents' needs and informed the facility she did not have the trach care training upon her hire. LVN G stated she did not receive trach care training from the facility. LVN G stated no one trained her on trach care and spoke with her about trach care when she started her shift on 08/29/25. LVN G stated she needed a trach care reeducation to meet residents' needs. LVN G stated she never was asked to perform trach care. LVN G stated she had not been trained on proper use of trach care equipment. LVN G stated she also did not receive periodic evaluations of trach care. LVN G stated she knew the importance of nurses being educated and competent in trach care and said, To make sure residents are good and safe. Residents could choke or die or get an infection. During an interview on 08/29/2025 at 10:55 a.m., LVN A stated he was trained on trach care 3-4 months ago. He stated he never performed trach care on a resident at the facility. He stated he felt like he would need supervision to perform trach care as he had only ever performed trach care on a mannequin. He stated he was never asked to perform trach care at the facility and had only provided residents with trach care supplies when they asked. LVN A stated although he had been trained on proper trach care and equipment, he had not received any periodic evaluations on his trach skills and knowledge. He stated he knew it was important to have trach care education because it was life threatening and residents could be at risk of airway obstruction and infection. He stated it would not be acceptable for a resident to wash their inner cannula in the sink because the water was not sterile. He stated he did not know Resident #1 was reusing his nasal cannulas and never observed him provide his own trach care. He stated he was not sure if Resident #1 had been trained on performing his own trach care. He stated Resident #1's trach collar was always clean, and he would replace the gauze when it was dirty.During an interview on 08/29/2025 at 11:27 p.m., the RDON stated staff were skill-checked every six months on trach care. The RDON stated 455862 Page 9 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the last check-off was early June and July of 2025. The RDON stated she was responsible for skill-checking nurses on trach care and knew it was important to educate nurses on trach care because residents could be at risk for any complication. The RDON stated she was still looking for staff competency evaluations. She expected staff to perform hand hygiene before and after any care and between glove changes. The RDON explained it was important to perform hand hygiene to protect themselves and the resident. The RDON expected staff to follow the Trach Care policy and procedure. Suction was necessary and expected to be applied at the bedside. She expected nurses to apply suction after hyperoxygenation (Breathing oxygen at higher than normal). The RDON stated she expected the nurses to hyperoxygenation the resident before applying suction. She expected the suction to be applied when pulling out the trach, not when going into the trach. The RDON stated she expected trach care equipment available at bedside for emergency services. During a telephone interview on 08/29/25 at 4:18 p.m., the NP stated if nurses were not comfortable and untrained in trach care, residents could be at risk of not receiving proper care, which they could develop infections, respiratory distress, and numerous other complications. The NP stated he was under the impression the RT was responsible for training nurses on trach care, but he had not seen the RT for quite some time. The NP stated he was unaware of how often the RT visited the facility .Interview with the Administrator and RDON on 08/28/2025 at 11:27 a.m., 08/29/2025 at 09:41 a.m., and 08/29/2025 at 1:46 p.m., staff competency skill checkoffs were requested at this time and it was not provided.Record review of facility's policy titled Suctioning the Lower Airway (Endotracheal or Tracheostomy Tube) revised October 2010 reflected: PurposeThe purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning.2. Review the resident's care plan to assess for any special needs of the resident.3. Obtain baseline vital signs and oxygen saturation from the resident's medical record.4. Obtain information about the resident's medical history, including date of intubation (tracheostomy), respiratory signs and symptoms, and risk factors for increased secretions, decreased airway clearance and/or airway obstruction (i.e., Chronic Obstructive Pulmonary Disease [COPD], chest trauma, abdominal surgery, and smoking).5. Assemble the equipment and supplies as needed.6. Test equipment before use. Determine if suction equipment is generating appropriate negative pressure. Use lower negative pressure with older residents whose oral mucosa is fragile.a. Wall suction units should be set between 100-120 mm Hg.b. Portable suction devices should have negative pressure set at 10-15 mmHg.General Guidelines1. Complications of suctioning the lower airway include trauma to the airway, infection, hypoxia, hypoxemia, and cardiac dysrhythmias (resulting from hypoxemia). To minimize the risk of complications, apply the following guidelines:a. Suction only as needed, based on assessment of the resident's level of respiratory distress.b. Use sterile equipment to avoid widespread pulmonary and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.).c. Hyperinflate the resident with a manual resuscitation (Ambu) bad (as ordered) before and after suctioning; andd. Hyperoxygenation the resident by increasing the oxygen flow (as ordered) before the procedure and between suctioning. (Note: After the procedure, oxygen should be readjusted as ordered to prevent oxygen toxicity and increased CO2 in COPD residents.)2. Monitor the resident's pulse and oxygen saturation (see procedure entitled Pulse Oximetry) during suctioning. If pulse decreases more than 20 beats per minute (8PM) or increases more than 40 8PM, or oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and re-ventilate and re-oxygenate the resident.Equipment and Supplies The following equipment and supplies will be necessary when 455862 Page 10 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some performing this procedure.1. Sterile suction catheter kit.2. Sterile drape.3. Sterile cup.4. Sterile gloves.5. #10 to #16 French catheter (catheter outer diameter should not exceed one-half the internal diameter of the tube);6. Sterile gauze.7. Towel or Chux pad.8. 100 cc sterile saline or sterile water.9. Resuscitation (Ambu) bag with supplemental oxygen. 10. Wall or portable unit.11. Tubing (approximately 6 feet); and12. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).Assessmentl . Identify the following risk factors for impaired airway clearance or aspiration:a. Impaired cough or gag reflex.b. Dysphagia; (difficulty swallowing)c. Weak respiratory muscles (from injury, abdominal surgery, etc.);d. COPD.e. Pulmonary infection.f. Presence of feeding tube.g. Smoking; and/orh. Decreased level of consciousness.2. Assess for the following signs and symptoms of respiratory distress/hypoxia/ hypoxemia:a. Diminished breath sounds.b. Tachypnea.c. Dyspnea.d. Gurgling, crackling or wheezing upon inspiration.e. Cyanosis.f. Decreased oxygen saturation (Sp02);g. Restlessness; and/orh. Drooling, secretions or vomitus in mouth.Steps in the Procedure1 . Provide for resident privacy.2. Explain the procedure to the resident.3. Perform hand antisepsis.4. Put on gloves. 5. Put on mask and protective eyewear (goggles or face shield), as indicated.6. Assist the resident to semi-Fowler's position with head turned toward you. If the resident is unconscious, place in lateral position facing you.7. Connect one end of suction tubing t 0 suction unit and place the other end near the resident.8. Turn on the suction unit and adjust to appropriate negative pressure (100-120 mmHg for wall unit or 10-15mmHg for portable unit9.Remove gloves.10. Open suction catheter kit.11. Place sterile drape across the resident's chest.12. Remove sterile cup, touching only the outside.13. Fill cup with I 00 cc sterile saline or sterile water.14. Apply sterile gloves. The dominant hand will remain sterile.15. Holding the catheter in dominant hand and the tubing in the non-dominant hand connect the catheter to the tubing.16-Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface (e.g., sterile drape or open catheter kit).17. Remove oxygen or humidity delivery device using non-dominant hand.18. Hyperinflate and hyper oxygenate the resident using an Ambu bag connected to supplemental oxygen.19. Manually ventilate (bag) the resident 4 to 5 times, coordinating with natural breaths. Remove bag.20. instruct the resident to inhale.21. Upon inhalation, insert the catheter into airway (ET tube or tracheostomy tube) without applying suction. Advance the catheter until resistance is met and/or resident coughs (at the [NAME]). Pull back I to2 cm.22. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than IO seconds.23. Re-ventilate and oxygenate the resident for a minimum of one minute between suctions.24. Rinse catheter and tubing with sterile saline or sterile water until clear.25. Assess cardio-pulmonary status.26. Repeat steps 20 through 24, if necessary. Limit suction passes to a maximum of three.27. Suction the oral or nasal cavity. (Note: Oropharyngeal and nasopharyngeal suctioning contaminate the catheter. Do not re-insert catheter into ET or tracheostomy tube.)28. Replace oxygen or humidity delivery device.29. If the resident's physical or medical condition permits, assist the resident to a position that promotes deep breathing and coughing.30. Turn off suction.31. Disconnect catheter from tubing. Wrap catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle.32.Remove drape and discard in designated receptacle.33. Discard water or saline in commode. Dispose of cup in designated receptacle.34. Empty and rinse collection container if necessary or as indicated by facility protocol.35. Discard personal protective equipment in designated he comfort receptacles. Wash resident, and dry if your hands thoroughly.36. Apply clean gloves and provide oral hygiene for the comfort of the resident, if indicated.37. Perform hand antisepsis.38. Reposition the bed covers. Make the resident comfortable.39. Place the call light within easy reach of the resident.40. If the resident 455862 Page 11 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Review of facility's policy titled Handwashing/Hand Hygiene revised August 2019 reflected: Policy Statement.1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventingthe transmission of healthcare-associated infections.Record review of the facility's Tracheostomy Care Policy, revised August of 2013, reflected it focused on the steps of replacing the trach and site and stoma care. It did not address physician orders or who should be providing care.This was determined to be an Immediate Jeopardy (IJ) on 08/28/2025 at 1:42 p.m. The ADM was notified. The ADM was provided with the IJ template on 08/28/2025 at 1:45 p.m . The following Plan of Removal was submitted by the facility and accepted on 09/05/25 at 1:45 p.m.:Plan of Removal (POR) - F695 POR Accepted at - 09/05/25 at 01:45 PMImmediate JeopardyOn 08/28/2025, an abbreviated survey was re-opened at the Facility. On the same date, the surveyor provided an Immediate Jeopardy (IJ) Template notification indicating that the facility failed to meet regulatory requirements under F695, placing Resident #1 at risk of serious harm due to lack of appropriate tracheostomy care.The IJ was triggered due to:Absence of physician orders for trach care, suctioning, and stoma monitoring. - Resident #1 performing his own trach care without documented training, oversight, or competency validation. - Evidence of potential harm, including pneumonia diagnosis and unsafe supply reuse.Action 1: Safe Discharge and Removal of Tracheostomy CapabilitiesEffective immediately as of 09/04/2025, the facility will remove all tracheostomy clinical capabilities. The 2 residents with tracheo[TRUNCATE 455862 Page 12 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for pain. The facility failed to: - Order Resident #1's Hydrocodone before it ran out, causing him to be excruciating pain for two days (08/10/25 - 08/12/25), resulting in him being sent to the ER.- Properly document the ordered PRN Hydrocodone administered to Resident #1 as his August 2025 MAR did not match the narc count sheet for his PRN Hydrocodone.- Assess Resident #1 for the effectiveness of his PRN Hydrocodone (as ordered) after it was administered during August 2025. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/12/25 at 4:49 PM. While the IJ was removed on 08/13/25 at 6:05 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life. Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in the body's tissues), tracheostomy status[KA1] , dysphagia (difficulty swallowing), chronic pain, and end-stage renal disease. Review of Resident #1's quarterly MDS assessment, dated 07/10/25, reflected a BIMS score of 14, indicating he was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected he required tracheostomy care. Section J (Health Conditions) reflected he had been hurting within the past five days and his pain occasionally affected his sleep, therapy activities, and day-to-day activities. Review of Resident #1's quarterly care plan, dated 04/16/25, reflected he required pain management D/T chronic pain r/t chronic physical back pain debility with an intervention of anticipating his need for pain relief and responding immediately to any complaint of pain. Review of Resident #1's hospital records, dated 07/09/25, reflected a discharge order for Acetaminophen-Hydrocodone (10/325 oral tablet) take by mouth every six hours as needed for pain. Review of Resident #1's physician order, dated 07/13/25, reflected Hydrocodone-Acetaminophen Oral Tablet 10-325 MG - Give 1 or 2 tablets every 4 to 6 hours as needed for pain. Review of Resident #1's August 2025 MAR, 08/01/25 - 08/12/25, reflected he was administered Hydrocodone on the following days: 08/01/25 - once08/04/25 - twice08/05/25 - three times08/06/25 once08/07/25 - once08/09/25 - twice Review of Resident #1's August 2025 narc sheet, from 08/01/25 08/12/25, reflected he was administered Hydrocodone on the following days: 08/01/25 - four times08/02/25 - three times08/04/25 - twice08/05/25 - four times08/06/25 - four times08/07/25 - four times08/08/25 - four times08/09/25 - four times08/10/25 - once He received his last dose (as it ran out) on 08/10/25 at 12:00 AM. Review of Resident #1's pain assessments, on 08/12/25, reflected the following numerical pain scales: 08/10/25 at 2:00 PM - 608/12/25 at 12:15 AM - 7 Review of Resident #1's physician order, undated, reflected a pain assessment before and after PRN medications: Utilize 0-10 pain scale or PAINAD. Document pain scale results, v/s, interventions, outcomes. Review of Resident #1's August 2025 MAR, 08/01/25 - 08/12/25, reflected the above order was never utilized/documented. Review of Resident #1's progress note, dated 08/10/25 at 2:49 PM and documented by LVN B, reflected the following: [Resident #1] walked over to writer in the hallway requesting to be sent to ER, saying, Can you please call the ambulance so I can go to the hospital. [Resident #1] walked over to writer several times earlier asking for main meds, Tylenol 650MG PO given, as Norco 10/325 supply got finished at midnight. Also offered to call NP on-call to obtain Tramadol or TYL#3 order, [Resident Residents Affected - Some 455862 Page 13 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #1] stated, Tramadol doesn't work for me and TYL3 makes me vomit. Review of Resident #1's progress note, dated 08/11/25 at 3:45 AM and documented by LVN B reflected 911 was called per his request due to complaining of chest pain. Review of Resident #1's hospital records, dated 08/11/25 at 4:35 AM reflected he was presenting from a nursing facility via EMS for chest pain onset today at 2:00 AM. He was administered Hydrocode at 5:04 AM. Review of Resident #1's progress note, dated 08/11/25 at 12:01 PM and documented by the IDON, reflected the following: [Resident #1] has returned from ER visit without new orders. Wants to go back out for pain control. Review of Resident #1's progress note, dated 08/12/25 at 7:20 AM and documented by LVN A, reflected the following: [Resident #1] complained of pain to this nurse and stated that he wanted to go to the hospital. This nurse notified the on-call practitioner. The on-call practitioner stated that the highest level of medication that he could prescribe was Tramadol, but he does not see the need to give orders for transfer to ER. [Resident #1] vocalized that he does not want Tramadol because it does not work. This nurse facilitated phone call for resident to paramedics. Review of Resident #1's physician order, dated 08/13/25, reflected Hydrocodone-Acetaminophen oral tablet 10-325 MG - Give 2 tablets orally every 6 hours as needed for pain. Review of Resident #1's August 2025 MAR, on 08/13/25, reflected at 11:49 AM he was administered the above order as his pain was rated at a 10. During a telephone interview on 08/12/25 at 9:33 AM, Resident #1's RP stated he had been out of his Hydrocodone since Saturday (08/10/25). He stated he had called her that morning crying telling her he hurt so bad and he felt like his body was going to burst. She stated she believed they were giving him Tylenol, but it obviously was not working. She stated he requested to go to the ER because he could not handle the pain. During an interview on 08/12/25 at 10:20, LVN A stated Resident #1 had requested to go to the hospital that morning because he was in excruciating pain. He stated he was out of his Hydrocodone, and it was not going to be able to be refilled until 08/20/25. He did not know what the plan was to manage his pain until then. He stated Resident #1 set an alarm to ensure he got the medication every six hours. LVN A stated if his MAR did not match the narc count sheet, it was because sometimes they (nursing staff) got busy and would forget to mark it off in the MAR. He stated he could see how it would look bad if they did not match, like the resident was possibly not getting the narcotic. During an interview on 08/12/25 at 12:52 PM, Resident #1's NP stated his expectations were that he be notified at least three days prior to a medication running out. He stated that would give ample time to ensure it was delivered on time. He stated he was not notified of Resident #1 running out of his Hydrocodone until yesterday, 08/11/25. He stated the order should not have read 1-2 tablets every 4-6 hours because the nurses should not have to determine whether they should give one or two and how often to administer them. He stated that order was made by his primary care doctor and was for more of a home setting. He stated his expectations were if they ran out of the Hydrocodone and he was in increased pain would be to try whatever they have or something in the e-kit. He stated he was not aware Resident #1 had been requesting the medication every six hours consistently. He stated if the pain was not being managed effectively, he would have tried a different medication or put another plan in place. He stated a MAR should always match the narc count sheet, especially for PRN pain medication. He stated if they were not matching, it could lead to a drug diversion. He stated his expectations were that nurses reevaluated a resident's pain after administering a PRN pain medication to ensure it was effective within 30 minutes to an hour. He stated if it was not effective, he would expect to be notified. During an interview on 08/12/25 at 2:44 PM, the RDON stated her expectations were that a MAR and a narc sheet always matched congruently. She stated they should be marked off in both places right as the medication was being administered. She stated the importance was to ensure medication errors did not occur and 455862 Page 14 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some that pain was adequately treated and managed. She stated PRN pain medications should always be followed-up on for effectiveness within 30 minutes to an hour. She stated nurses should notify the NP when a medication is getting low within seven days. She stated the pharmacy would not dispense any more of Resident #1's Hydrocodone because they had would not dispense more than what the max was in a 30-day period. She stated it would have been different if it had been scheduled instead of PRN. She stated someone with the kind of pain Resident #1 had should have been on pain management. Review of the facility's Pain Policy, revised March 2018, reflected the following: 1. With input from the resident to the extent possible, the physician and staff will establish goals of paintreatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. Monitoring: 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain.a. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 2. The staff will evaluate and report the resident/patients use of standing and PRN analgesics. a. Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. b. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding nonpharmacological measures. Review of the facility's Medication Orders Policy, revised November 2014, reflected the following: 2. PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. Review of the facility's Administering Medications Policy, revised April 2019, reflected the following: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.28. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. Review of the facility's Documentation of Medication Administration Policy, revised April 2017, reflected the following: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR).2. Administration of medication must be documented immediately after (never before) it is given. The RDON was notified on 08/12/25 at 4:49 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 08/13/25 at 3:53 PM: Action 1: Immediate Medication Access and Resident SupportStart Date: transfer of resident to ER, at his request. NP was notified of transfer but order was not given to transfer. -Resident returned to facility @1500 without any new orders. -Medication was dispensed by (pharmacy) and is onsite now. Residents pain has been assessed on an ongoing basis. Action 2: Staff Education and -Regional DON (Acting DON) reviewed all policies and procedures below and started a PIP for Pain Control, Monitoring and Satisfaction aligning with POR for F697. On 8/12/25, via Teams conference, CEO reviewed Policy and Procedures, PIP and POR with Reg DON to ensure understanding of P&P, PIP and POR with satisfactory results. - All licensed staff 455862 Page 15 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some (RN, LVN) were re-educated on pain management standards, MAR documentation, and narcotic reconciliation and were re-educated on protocols for medication ordering and inventory tracking.-Audit completed to determine all residents with PRN narcotic pain medication orders was completed and resident surveys were implemented to determine if residents are satisfied with current pain regimen or had pain control issues to report based on initial audit; no further resident concerns were identified during initial audit. Of the 28 residents identified: all other residents PRN narcotics were in stock or reordered accordingly. - Pain monitoring protocols were initiated and being monitored by DON for 28 residents receiving PRN narcotics (opioids) for pain control based on initial audit. - Competency checks were completed and filed; all licensed staff was re-educated using competency 2025 Pain Medication Competency; unavailable staff will be educated, and competency completed prior to next shift worked; all PCC access has been reset to ensure that education is completed prior to start of work for all licensed staff. -Moving forward, all new hires, Agency and PRN staff will be educated on the 2025 Pain management Competency and Policy Review prior to being issued PCC access during orientation. Action 3: Systemic weekly for 60 days)Responsible: Regional Director of Nursing / QAPI Committee - Daily audits of MARs and narcotic logs initiated.- Weekly resident interviews to assess pain management satisfaction.- Oversight reports submitted to QAPI for review and corrective planning for 3 months or until a plan is found to be sustainable for long term prevention of reoccurrence. The Surveyor monitored the POR on 08/13/25 as followed: Observation on 08/13/25 from 4:02 PM - 4:10 PM revealed three residents' PRN pain medication matching their narcotic count sheets from LVN B's cart. During an interview on 08/13/25 at 4:35, Resident #1 stated over the weekend (08/10/25 - 08/12/25) he was in so much pain to his back and his legs. He stated they felt like they were pulsing or stabbing. When asked to rate the pain from 1 to 10, he stated, A 20! He stated he was not currently in pain as he received his pain medication earlier that morning (08/13/25). During an interview on 08/13/25 at 4:48 PM, LVN B stated she had worked over the weekend when Resident #1 had run out of his Hydrocodone. She stated he was in pain, but his RP was who normally supplied the medication. She stated she offered him Tramadol which he refused, so she planned on having the NP assess him on his next visit to see what else could be done. During an interview on 08/13/25 at 4:55 PM, the RDON stated she and the CEO reviewed all policies on pain management and reordering medications the evening before (08/12/25). She stated the staff work 12-hour shifts and they night staff were in-serviced that morning as well as the day shift. She stated she removed all nurse's access from PCC so they would not be able to work until they were-serviced. She stated Resident #1's Hydrocodone was picked up the day before. During interviews on 08/13/25 from 4:48 PM - 6:00 PM, LVN B, RN C, LVN D, LVN E, and RN F (nurses from both shifts) all stated they were in-serviced on pain management, medication reconciliation, and re-ordering medications in timely manner. They all stated medications should be re-ordered within five days of it running out. They stated when administering a PRN narcotic, it needed to be documented the resident's MAR and the narcotic sheet. They stated PRN pain medication needed to be monitored for effectiveness within an hour of administration. They stated if pain was not being managed, they would notify the NP immediately. They all stated if a resident was not able to rate pain with the numerical pain scale, they would look for signs such as agitation, facial grimacing, or moaning. Review of the facility's Ad hoc QAPI Agenda, dated 08/12/25, reflected the RDON, the ADON, the MD, and the NP were in attendance. Review of an email, dated 08/13/25 and sent by the facility's CEO, reflected the following: I reviewed policy and procedure and re-educated with the [RDON] on: pain management standards, MAR documentation, narcotic reconciliation, med ordering and inventory tracking; a 455862 Page 16 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some PIP was started and reviewed via Teams. Review of an in-service, dated 08/13/25 and conducted by the RDON, reflected nurses from all shifts were in-serviced on the facility policies regarding pain medication administration, medication orders and documentation, pain-clinical protocol, narcotic reconciliation, and medication ordering and inventory tracking. Review of Licensed Nurse Competency quizzes, dated 08/13/25, reflected all nurses completed the quiz on pain management and medication administration with no concerns. Review of physician orders for 28 residents (including Resident #1) with orders for PRN pain medication, dated 08/13/25, reflected an order for pain monitoring Q shift and PRN, using PAINAD or number scale. If pain unrelieved post pain medication - call provider immediately. Review of Resident #1's August 2025 MAR and his narcotic count sheet, on 08/13/25, reflected he was administered Hydrocodone that day (08/13/25) at 11:49 AM. The RDON was notified on 08/13/25 at 6:05 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. 455862 Page 17 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one of three Residents (Resident #4) reviewed for competent nursing staff.LVN E failed to provide trach care and suctioning to Resident #4 according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 08/28/2025. While the IJ was removed on 09/05/2025, the facility remained at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risks for infection, respiratory distress, hospitalization and death.Findings include:Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old male with original admission date of [DATE] and readmission date of [DATE]. Resident #4 had diagnoses which included tracheostomy status (a surgical procedure that creates an opening in the trachea-windpipe to allow breathing), acute and chronic Respiratory failure with hypoxia (Hypoxia is a condition in which there is an inadequate supply of oxygen to the body's tissues), Gastrostomy status (refers to the presence of a surgical opening in the stomach that allows for the insertion of a tube for feeding or other purposes), acute on chronic systolic Congestive heart failure (a condition where a sudden worsening of symptoms occurs in some who already has chronic systolic heart failure), cerebral infarction (occurs when blood flow in the brain is interrupted, leading to cell death and brain damage), and dysphagia (difficulty swallowing).Record review of Resident #4's quarterly MDS assessment, dated 08/20/2025, reflected a BIMS score of 00, which indicated severe cognitive impairment. Staff assessment reflected Resident #4 had both short-term and long-term memory problems. Section O reflected Resident #4 required Oxygen therapy, suctioning and tracheostomy care.Record review of Resident #4's care plan, initiated 01/14/2025, reflected Resident #4 had tracheostomy related to impaired breathing mechanics and was on oxygen at 4LPM, Resident #4 was NPO.Record review of Resident #4's physician orders, dated 05/08/2025, reflected: Suction as needed to maintain patency every 1 hours as needed for as needed to maintain patency of trach. Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. one time a day for Reduce risk of infection 6-inch trachRecord review of Resident #4's physician orders, dated 06/23/2025, reflected: Monitor trach for placement every shift.Record review of Resident #4's physician orders, dated 08/29/2025, reflected: Monitor trach stoma site for issues including but not limited to: S/S of infection, irritation, redness, swelling, pain, mucosal tissue issues. Notify MD or NP for any findings which are abnormal and complete progress note. every shift for tracheostomy care Notify for abnormal findings and complete progress note. Trach care daily and PRN: For disposable: (Trach Canula size 7.5) remove and dispose of inner cannula. Replace with new inner cannula, gauze, and collar. one time a day for Reduce risk of infection Inner Canula Size [NAME] 7.5During an observation on 08/29/2025 at 08:46 AM, Resident #4 was observed lying in bed with the HOB elevated at about 30 degrees, Resident #4 was observed with excessive secretions from his trach, oxygen mask full of secretions, secretions dripping down Resident #4's left neck and shoulder, trach tide and split gauze under trach saturated secretions. Resident #4 was noted on continuous oxygen via mask at 4 L per hour using the oxygen concentrator. Surveyors called for help to Resident #4's room, 455862 Page 18 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some that Resident #4 needed a nurse. LVN G stated Resident #4's nurse was somewhere down the hall. LNV G walked down the hall could not see Resident #4's nurse assigned for the day and walked to Resident #4's room. LVN G went in Resident #4's room, looked at Resident #4, turned around a little in Resident #4's room without touching him and walked out of the room. At about 8:58 a.m. Resident #4's assigned nurse, LVN E walked to Resident #4's door and stated she was going to perform trach care and suctioning on Resident #4 .Observation on 08/29/25 at 09:03 a.m. revealed LVN E collecting supplies to perform trach care on Resident #4. LVN E was observed collecting supplies from the medication cart such as trach kit and a 10cc vial of normal saline. LVN E donned an isolation gown and a clean glove without performing hand hygiene . LVN E took clean gauze wiped Resident #4's oxygen mask removing the excess secretions, then wiped Resident #4's left neck and shoulder removing excess secretions. LVN E then reached into her pants pocket with her soiled gloved hand and pulled a glove out . LVN E then removed the glove from 1 hand, reached in her pants pocket again but did not get anything. LVN E removed gloves from the other hand and walked out to the doorway to get more gloves from her medication cart, which was parked in the doorway. LVN E grabbed more gloves from her medication cart and placed gloves in her pants pocket. LVN E applied clean gloves without hand hygiene, took the yankauer (A Yankauer is a medical suction device used to remove fluids, blood, secretions, and debris from a patient's oral airway or surgical site to prevent aspiration and maintain a clear field for healthcare providers.) and inserted it into Resident #4's trach, suctioning while going in and coming out of the trach. LVN E used water which she took from a normal saline vial (10 cc), put water in a plastic cup which was not sterile to clean the yankauer. LVN E again inserted the yankauer into Resident #4's trach, with the yankauer not being sterile, and again applied suction while going in and coming out. LVN E removed soiled gloves, no hand hygiene, reached in her pants pocket for clean gloves, the nurse applied clean gloves, applied split gauze under Resident #4's trach, did not clean Resident #4's trach stoma, did not change Resident #4's trach tide even though it was saturated with secretions. LVN E did not check Resident #4's oxygen prior to trach care or suctioning or hyper-oxygenate Resident #4 during the procedure. Resident #4 was noted kicking the wall and the window each time suction was applied.During an interview on 08/29/2025 at 10:12 a.m., LVN E stated nurses were responsible for performing trach care on residents. LVN E stated the RDON was responsible for training nurses on trach care. LVN E stated she felt she had the trach care training/skills to meet residents' needs, but she sometimes did not have what she needed to perform trach care. LVN E explained she felt she did not have and could not find the trach care equipment to perform trach care. LVN E stated she did not receive trach care training and proper use of trach care equipment. LVN E stated no one spoke with her about trach care when she started her shift on 08/29/2025. LVN E stated she did not receive periodic evaluations of her trach skills and knowledge from the facility. LVN E stated she felt the facility needed to reeducate nurses on trach care and said, Because nurses may forget certain steps in the procedure. If you did not work hands on, there were certain things you didn't remember. Residents could be at risk of having trouble breathing, becoming confused, and becoming combative. Critical case. Has to do with the airway when it comes to the breathing and has to do with infection. Residents could acquire an infection when it came to lack of breathing due to lack of trach care competency. LVN E stated she knew to suction a resident depending on when a resident choked on phlegm. LVN E stated she did not perform trach care for Resident #4 because she did not see the water to use . LVN E stated she observed Resident #4 had excessive secretions around his neck and shoulder. LVN E stated she used normal saline during Resident #4's trach care. LVN E stated she had to go to another unit to get the trach equipment to perform trach care because she did not see the equipment 455862 Page 19 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some available on her unit. LVN E stated she was not familiar with Resident #4. LVN E stated the nurses needed inner cannula for emergency purposes, oxygen mask, sterile water, cannister when performing trach care .During an interview on 08/29/2025 at 10:34 a.m., LVN G stated nurses were responsible for performing trach care on residents. LVN G stated she did not know who was responsible for training nurses on trach care. LVN G stated she felt she did not have the trach care training to meet residents' needs and informed the facility she did not have the trach care training upon her hire. LVN G stated she did not receive trach care training from the facility. LVN G stated no one trained her on trach care and spoke with her about trach care when she started her shift on 08/29/25. LVN G stated she needed a trach care reeducation to meet residents' needs. LVN G stated she never was asked to perform trach care. LVN G stated she had not been trained on proper use of trach care equipment. LVN G stated she also did not receive periodic evaluations of trach care. LVN G stated she knew the importance of nurses being educated and competent in trach care and said, To make sure residents are good and safe. Residents could choke or die or get an infection. During an interview on 08/29/2025 at 10:55 a.m., LVN A stated he was trained on trach care 3-4 months ago. He stated he never performed trach care on a resident at the facility. He stated he felt like he would need supervision to perform trach care as he had only ever performed trach care on a mannequin. He stated he was never asked to perform trach care at the facility and had only provided residents with trach care supplies when they asked. LVN A stated although he had been trained on proper trach care and equipment, he had not received any periodic evaluations on his trach skills and knowledge. He stated he knew it was important to have trach care education because it was life threatening and residents could be at risk of airway obstruction and infection. He stated it would not be acceptable for a resident to wash their inner cannula in the sink because the water was not sterile. During an interview on 08/29/2025 at 11:27 p.m., the RDON stated staff were skill-checked every six months on trach care. The RDON stated the last check-off was early June and July of 2025. The RDON stated she was responsible for skill-checking nurses on trach care and knew it was important to educate nurses on trach care because residents could be at risk for any complication. The RDON stated she was still looking for staff competency evaluations. She expected staff to perform hand hygiene before and after any care and between glove changes. The RDON explained it was important to perform hand hygiene to protect themselves and the resident. The RDON expected staff to follow the Trach Care policy and procedure. Suction was necessary and expected to be applied at the bedside. She expected nurses to apply suction after hyperoxygenation (Breathing oxygen at higher than normal). The RDON stated she expected the nurses to hyperoxygenation the resident before applying suction. She expected the suction to be applied when pulling out the trach, not when going into the trach. The RDON stated she expected trach care equipment available at bedside for emergency services. During a telephone interview on 08/29/25 at 4:18 p.m., the NP stated if nurses were not comfortable and untrained in trach care, residents could be at risk of not receiving proper care, which they could develop infections, respiratory distress, and numerous other complications. The NP stated he was under the impression the RT was responsible for training nurses on trach care, but he had not seen the RT for quite some time. The NP stated he was unaware of how often the RT visited the facility .Interview with the Administrator and RDON on 08/28/2025 at 11:27 a.m., 08/29/2025 at 09:41 a.m., and 08/29/2025 at 1:46 p.m., staff competency skill checkoffs were requested at this time and it was not provided.Record review of facility's policy titled Suctioning the Lower Airway (Endotracheal or Tracheostomy Tube) revised October 2010 reflected: PurposeThe purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.Preparation1. Verify that there is a physician's order for this procedure. 455862 Page 20 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review the physician's orders or facility protocol for suctioning.2. Review the resident's care plan to assess for any special needs of the resident.3. Obtain baseline vital signs and oxygen saturation from the resident's medical record.4. Obtain information about the resident's medical history, including date of intubation (tracheostomy), respiratory signs and symptoms, and risk factors for increased secretions, decreased airway clearance and/or airway obstruction (i.e., Chronic Obstructive Pulmonary Disease [COPD], chest trauma, abdominal surgery, and smoking).5. Assemble the equipment and supplies as needed.6. Test equipment before use. Determine if suction equipment is generating appropriate negative pressure. Use lower negative pressure with older residents whose oral mucosa is fragile.a. Wall suction units should be set between 100-120 mm Hg.b. Portable suction devices should have negative pressure set at 10-15 mmHg.General Guidelines1. Complications of suctioning the lower airway include trauma to the airway, infection, hypoxia, hypoxemia, and cardiac dysrhythmias (resulting from hypoxemia). To minimize the risk of complications, apply the following guidelines:a. Suction only as needed, based on assessment of the resident's level of respiratory distress.b. Use sterile equipment to avoid widespread pulmonary and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.).c. Hyperinflate the resident with a manual resuscitation (Ambu) bad (as ordered) before and after suctioning; andd. Hyperoxygenation the resident by increasing the oxygen flow (as ordered) before the procedure and between suctioning. (Note: After the procedure, oxygen should be readjusted as ordered to prevent oxygen toxicity and increased CO2 in COPD residents.)2. Monitor the resident's pulse and oxygen saturation (see procedure entitled Pulse Oximetry) during suctioning. If pulse decreases more than 20 beats per minute (8PM) or increases more than 40 8PM, or oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and re ventilate and re-oxygenate the resident.Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure.1. Sterile suction catheter kit.2. Sterile drape.3. Sterile cup.4. Sterile gloves.5. #10 to #16 French catheter (catheter outer diameter should not exceed one-half the internal diameter of the tube);6. Sterile gauze.7. Towel or Chux pad.8. 100 cc sterile saline or sterile water.9. Resuscitation (Ambu) bag with supplemental oxygen. 10. Wall or portable unit.11. Tubing (approximately 6 feet); and12. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).Assessmentl . Identify the following risk factors for impaired airway clearance or aspiration:a. Impaired cough or gag reflex.b. Dysphagia; (difficulty swallowing)c. Weak respiratory muscles (from injury, abdominal surgery, etc.);d. COPD.e. Pulmonary infection.f. Presence of feeding tube.g. Smoking; and/orh. Decreased level of consciousness.2. Assess for the following signs and symptoms of respiratory distress/hypoxia/ hypoxemia:a. Diminished breath sounds.b. Tachypnea.c. Dyspnea.d. Gurgling, crackling or wheezing upon inspiration.e. Cyanosis.f. Decreased oxygen saturation (Sp02);g. Restlessness; and/orh. Drooling, secretions or vomitus in mouth.Steps in the Procedure1 . Provide for resident privacy.2. Explain the procedure to the resident.3. Perform hand antisepsis.4. Put on gloves. 5. Put on mask and protective eyewear (goggles or face shield), as indicated.6. Assist the resident to semi-Fowler's position with head turned toward you. If the resident is unconscious, place in lateral position facing you.7. Connect one end of suction tubing t 0 suction unit and place the other end near the resident.8. Turn on the suction unit and adjust to appropriate negative pressure (100-120 mmHg for wall unit or 10-15mmHg for portable unit9.Remove gloves.10. Open suction catheter kit.11. Place sterile drape across the resident's chest.12. Remove sterile cup, touching only the outside.13. Fill cup with I 00 cc sterile saline or sterile water.14. Apply sterile gloves. The dominant hand will remain sterile.15. Holding the catheter in dominant hand and the tubing in the non-dominant hand connect 455862 Page 21 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the catheter to the tubing.16-Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface (e.g., sterile drape or open catheter kit).17. Remove oxygen or humidity delivery device using non-dominant hand.18. Hyperinflate and hyper oxygenate the resident using an Ambu bag connected to supplemental oxygen.19. Manually ventilate (bag) the resident 4 to 5 times, coordinating with natural breaths. Remove bag.20. instruct the resident to inhale.21. Upon inhalation, insert the catheter into airway (ET tube or tracheostomy tube) without applying suction. Advance the catheter until resistance is met and/or resident coughs (at the [NAME]). Pull back I to2 cm.22. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than IO seconds.23. Re-ventilate and oxygenate the resident for a minimum of one minute between suctions.24. Rinse catheter and tubing with sterile saline or sterile water until clear.25. Assess cardio-pulmonary status.26. Repeat steps 20 through 24, if necessary. Limit suction passes to a maximum of three.27. Suction the oral or nasal cavity. (Note: Oropharyngeal and nasopharyngeal suctioning contaminate the catheter. Do not re-insert catheter into ET or tracheostomy tube.)28. Replace oxygen or humidity delivery device.29. If the resident's physical or medical condition permits, assist the resident to a position that promotes deep breathing and coughing.30. Turn off suction.31. Disconnect catheter from tubing. Wrap catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle.32.Remove drape and discard in designated receptacle.33. Discard water or saline in commode. Dispose of cup in designated receptacle.34. Empty and rinse collection container if necessary or as indicated by facility protocol.35. Discard personal protective equipment in designated he comfort receptacles. Wash resident, and dry if your hands thoroughly.36. Apply clean gloves and provide oral hygiene for the comfort of the resident, if indicated.37. Perform hand antisepsis.38. Reposition the bed covers. Make the resident comfortable.39. Place the call light within easy reach of the resident.40. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Review of facility's policy titled Handwashing/Hand Hygiene revised August 2019 reflected: Policy Statement.1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventingthe transmission of healthcare-associated infections. This was determined to be an Immediate Jeopardy (IJ) on 08/28/2025 at 1:42 p.m. The ADM was notified. The ADM was provided with the IJ template on 08/28/2025 at 1:45 p.m . The following Plan of Removal submitted by the facility was accepted on 09/05/25 at 1:45 p.m.:Plan of Removal - F726 POR Accepted on: 09/05/25 at 01:45 PM Immediate JeopardyOn 08/29/2025, an abbreviated survey was initiated at the Facility. On the same date, the surveyor provided an Immediate Jeopardy (IJ) notification indicating that the facility failed to meet regulatory requirements under F726, placing Resident #2 and potentially others at risk due to lack of competent tracheostomy care.The IJ was triggered due to:- Nurses performing trach care without proper training or competency validation.- Observed unsafe practices including lack of hand hygiene, improper suctioning technique, and absence of oxygenation.- No documented trach care competencies or evaluations for nursing staff.Action 1: Safe Discharge and Removal of Tracheostomy CapabilitiesEffective immediately as of 09/04/2025, the facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies will be safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.Residents #2 and #3 were identified as potentially affected and will be discharged accordingly. They have been assessed by Consultant RN and found to be safe, unaffected by deficiencies and in no distress. They will be discharged immediately upon formulation of discharge plan. Resident #2 will be discharged to SNF and Resident #3 will be discharged to hospital pending SNF placement due to need 455862 Page 22 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Notification of Tracheostomy Capability Removal Regarding refusals of care and non-compliance with ordered nursing treatments and resident education if preference of resident is to complete clinical tasks, this education will extend to all nursing related tasks which any resident has taken upon themselves for self-provided care- A Special Bulletin inservice with sign-in sheet. This was initially completed with DON on 8/30/2025; RN consultant to review. The Facility does not maintain a policy for residents to provide their own treatments outside of self-administration of medication; if a resident refuses or is non-compliant with ordered nursing procedures or treatments it will be documented in progress notes, physician notified, and care plan will be updated. All clinical staff and admissions team members have been notified by mass message that we will no longer accept residents or referrals for tracheostomy dependent residents. Start Resident Discharge and DocumentationEffective immediately as of 09/04/2025, the facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies have been safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the and MonitoringAction: IJ and POR reviewed during adhoc QAPI with medical director, administrator, outside consultant and DON; POR and POC will be reviewed during monthly QAPI X3 months and revised as needed, to sustain improvement. A second adhoc QAPI was conducted via teleconference to update education plan and review of revisions. A third adhoc QAPI was conducted including RT to discuss further areas of revision to POR and engagement of RT, duties and oversight responsibilities. A fourth QAPI will be held to notify and discuss plan and new clinical capabilities with medical director. Start Date: following: An observation on 09/05/25 at 10:15 AM confirmed Resident #2 and Resident #3 were no longer in the building, and no other tracheostomy residents resided in the facility. In an interview on 09/05/25 at 01:27 PM with SW he stated he was contacted by the ADM advising that they had to discharge Resident #2 and Resident #3; the discharge was occurring due to nursing staff lacking the competencies to care for their tracheostomy and facility clinical capabilities changing. SW confirmed Resident #2 was discharged to [SNF B] on 09/04/25 and that Resident #3 was discharged to the hospital on [DATE] and would be discharged to [SNF B] after discharging from the hospital and not returning to the facility. In an interview on 09/05/25 at 05:19 PM with the ADM, she confirmed that both Resident #2 and Resident #3 were discharged from the facility on 09/04/25. She stated Resident #2 was discharged to [SNF B] and that Resident #3 would not be returning from the hospital and would be sent to [SNF B] upon her discharge from the hospital. She stated this was due to the facility changing their clinical capabilities as of 09/05/25 due to not having staff capable of caring for residents with tracheostomies and therefore the facility would not be admitting them. The ADM stated that the message advising staff of the changes in clinical capabilities was sent by the DON to the leadership team that facilitates in new referrals and admissions and makes the decisions of those being admitted ; she stated this included the BOM and SW and provided evidence for review which included the message sent. In an interview on 09/05/25 at 06:34 with DON she confirmed the clinical capabilities changing and notice provided to those that handle admissions such as ADM and SW and notification made to medical director with QAPI meeting, with confirmation of Resident #2 and #3 not returning resulting in no more trach residents in the facility to constitute immediacy. Record review of Resident #2's progress notes reflected a nursing note dated 09/04/25, Resident discharged to [SNF B] via wheelchair with the assistance of transporter 455862 Page 23 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and nurse. Personal belongings and medications transfer with resident upon discharge.Record Review of Resident #3's progress notes reflected Resident #3 was discharged to the hospital on [DATE] due to abnormal chest x-ray. A separate progress note entered 09/05/25 by the ADM reflected arrangements made for Resident #3 to go to [SNF B] after discharge from the hospital. Review of text message sent to staff on 09/05/25 in mass message system reflected message that came from DON to staff Please let it be known from this moment forward that our clinical capabilities have changed, and we will no longer be accepting residents who are tracheostomy dependent. The text reflected was sent to department heads. Review of AdHOC QAPI for IJ F695 and F726 dated 09/04/25 reflected: Action: IJ and POR reviewed with medical director, administrator, RN consultant and DON. POR and POC will be reviewed during monthly QAPI X3 months and revised as needed, to sustain improvement. The facility clinical capabilities were discussed, as well as recent decision to transfer all current tracheostomy patients to other facilities/safe medical facility. It was agreed upon that facility will no longer accept new tracheostomy patients for admission.The ADM was informed the Immediate Jeopardy was removed on 08/28/2025 at 4:41 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 455862 Page 24 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 2 of 4 residents (Resident #2, and Resident #3) reviewed for pressure ulcers.The facility failed to follow the physician's orders for providing wound care for Resident #2 and Resident #3, on a regular basis.This failure could place residents at risk of worsening their wounds. Findings Include: 1. Record review of Resident #2's face sheet, dated 09/05/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acute congestive heart failure ( sudden and severe failure of the heart) , obesity, asthma, acute respiratory failure and edema (Swelling). Record review of Resident #2's initial MDS, dated [DATE], revealed a BIMS score of 15, which indicated his cognition was intact. Resident #2 had the risk of pressure ulcers/injuries and the recommended applications of ointments. Record review of Resident #2's care plan, dated 08/13/25, reflected the resident was potential for impairment to skin integrity r/t lymphedema (swelling due to fluid accumulation). The relevant intervention was identifying potential causative factors and resolve where possible. Record review of Resident #2's comprehensive skin assessment, conducted by the WNP on 08/22/25, reflected: [Resident #2] was seen today as part of a facility-wide skin sweep. dry skin noted. No open area. emollient recommended. No redness noted to bilateral heel and buttock. Record review of Resident #2's physician order, dated 08/29/25, reflected: Cleanse buttock with wound cleanser, apply triad paste and collagen mixture. leave open to air QD and PRN for wound care. -Start Date-08/29/2025. Record review on 09/05/25 of Resident #2's TAR for August and September 2025 reflected he did not receive the treatment ordered by the physician, on 08/30/25, 08/31/25, 09/01/25 and 09/02/25. An observation of Resident #3's wound on 09/05/25 at 3:30pm revealed no infection or worsening of wound from the initial assessment. 2. Record review of Resident #3's face sheet, dated 09/05/25, reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. The diagnoses included chronic obstructive pulmonary disease (difficult to breath), muscle weakness, end stage renal disease (final stage of kidney disease) , hypertension, and pressure ulcer of right buttock and sacral region( area at the base of spine above the tail bone ). Record review of Resident #3's quarterly MDS ,dated 08/05/25, reflected the BIMS interview could not be conducted as the resident rarely/never understood the interview questions. Resident #1 was at high risk for pressure ulcer/injuries and the interventions were, the application of nonsurgical dressings and ointments/medications Record review of Resident #3's care plan, dated 06/25/25, reflected she had a pressure ulcer to her left upper extremity. The relevant interventions were, cleansed gently with normal saline or wound cleanser daily and applying skin prep and leave open to air until resolved. Record review of Resident #3's comprehensive skin assessment, conducted by WNP, on 08/22/25, reflected: [Resident #3] was seen today as part of a facility-wide skin sweep. Dry skin noted. No open area. Emollient (cream that moisturizing the skin) recommended. No redness noted to bilateral heel and buttock. Record review of the progress note in the her, dated 08/28/25, authored by WN, reflected: Staff notified this nurse [WN] that resident was bleeding during shower. On inspection, resident observed to have stage 2 [pressure ulcer] at coccyx, measuring 2cm x 2cm x 1cm depth. NP notified. Record Review of Resident #3's physician's order reflected:1. Cleanse stage 2 to coccyx with wound cleanser, apply calcium alginate, and dry dressing/ QD and PRN every day shift for wound care. -Start Date-08/29/20252. Cover left arm blister with dry dressing every day and night shift for wound care. -Start Date-09/01/2025. Record review on 09/05/25 of Resident #3's TAR for August and September 455862 Page 25 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2025 reflected she did not receive the treatment ordered by the physician, on 08/30/25, 08/31/25, 09/01/25 and 09/02/25. An observation of Resident #3's wound on 09/05/25 at 3:20pm revealed no infection or worsening of wound from the initial assessment. Attempted interview on 09/05/25 at 4:30 PM by phone to WN was unsuccessful. A voice message was left and no return call received . During an interview on 09/05/25 at 2:20 PM, the ADON. She stated she was doing the wound care at the facility on this day, as the WN was on leave. When the investigator pointed out that there were days when the wound care was not provided to Resident #1 and Resident #2, the ADON stated it was important to adhere to the treatment order and provide the treatment per the order to residents on a regular basis. She stated if the treatment was not provided as ordered by the physician, the wound could get worsened and put the residents in danger. She stated it was the responsibility of the WN to make sure the treatment was done as ordered. During an interview on 09/05/25 at 4:15 PM, LVN G stated. She said wound care was the responsibility of the WN, however in the absence of the WN, it was the responsibility of the nurses on duty to perform wound care in the hall that was assigned to them. LVN G said administering medications and treatment as per the physician's order was important for the well-being of the residents. She stated sometimes the nurses on duty were unaware the WN was absent on that day and would not provide treatment thinking the WN would complete the wound care. She added; thus, the residents could miss wound care on those days. During a telephone interview on 09/05/25 at 3:45 PM, the WNP stated during her visit on 08/22/25 she visited Resident #4 and Resident #3. She stated on 08/22/25 both the residents' skin condition was okay and there was nothing substantial going on with their skin. She stated during her visit on 08/25/25, she noticed a superficial skin issue on Resident #4's left buttock area. She stated she placed a treatment order to resolve the issue at the initial stages to stop developing further. The WNP stated the staff at the facility reported to her, on 08/28/25, about the newly developed wound on Resident #3's coccyx area and a treatment order was placed to take care of it. The WNP stated her expectation was the staff commence the treatment as soon as possible once the order was placed and they should stick to the frequency of the treatment as per the order. She said most of the time the wound care was done once a day, however frequency could vary depending on the condition and severity of the wound, hence adhering to the treatment order was very important for the fast recovery. During an interview on 09/05/25 at 4:50 PM, the ADM stated she was new at the facility and got to know the system. She said administering medications and treatment in a timely manner without any omissions was important for the well-being of the residents. She stated there was no excuse for not providing them at any point of time. The ADM stated it was the responsibility of the DON (who was on leave currently) to make sure the medication administration and treatment were done as per the physicians, on a day-to-day basis. She stated she was not sure if the DON conducted MAR and TAR audits regularly to identify mistakes, that included omissions in administering treatments and medications at the facility Record review of the facility's policy titled Administering Medications revised in April 2019, reflected: Medications are administered in a safe and timely manner, and as prescribed. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be ‘flagged.' After completing the medication pass, the nurse will return to the missed resident to administer the medication.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Record review of the facility's policy titled Wound Care revised in October 2010, reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Verify that there is a physician's order for this procedure.2. Review the resident's care plan to assess for any special needs of the resident.a. For example, the resident may have PRN 455862 Page 26 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orders for pain medication to be administered prior to wouldcare.The following information should be recorded in the resident's medical record:1. The type of wound care given.2. The date and time the wound care was given.3. The position in which the resident was placed.4. The name and title of the individual performing the wound care.5. Any change in the resident's condition.6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.7. How the resident tolerated the procedure.8. Any problems or complaints made by the resident related to the procedure9. If the resident refused the treatment and the reason(s) why.10. The signature and title of the person recording the data. 455862 Page 27 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in one of three residents (Resident #4) review for infection control. 1. LVN E failed to perform hand hygiene before and after glove changes while performing trach care and suctioning on Resident #4. 2. LVN E failed to follow sterile technique while Suctioning Resident 42. These deficient practices could place residents at risks for infection, respiratory distress, hospitalization.Findings include:Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old male with an original admission date of 01/13/2025 and readmission date of 05/06/2025. Resident #4 had diagnoses which included tracheostomy status (a surgical procedure that creates an opening in the trachea-windpipe to allow breathing), acute and chronic Respiratory failure with hypoxia (Hypoxia is a condition in which there is an inadequate supply of oxygen to the body's tissues), Gastrostomy status (refers to the presence of a surgical opening in the stomach that allows for the insertion of a tube for feeding or other purposes), acute on chronic systolic Congestive heart failure (a condition where a sudden worsening of symptoms occurs in some who already has chronic systolic heart failure), cerebral infarction (occurs when blood flow in the brain is interrupted, leading to cell death and brain damage), and dysphagia (difficulty swallowing). Record review of Resident #4's quarterly MDS assessment, dated 08/20/2025, reflected BIMS score of 00, which indicated severe cognitive impairment. The staff assessment reflected Resident #4 had both short-term and long-term memory problems. Section O reflected Resident #4 required Oxygen therapy, suctioning and tracheostomy care.Record review of Resident #4's care plan, initiated 01/14/2025, reflected Resident #4 had a tracheostomy related to impaired breathing mechanics and was on oxygen at 4LPM, Resident #4 was NPO.Record review of Resident #4's physician orders, dated 05/08/2025, reflected: Suction as needed to maintain patency every 1 hours as needed for as needed to maintain patency of trach. Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. one time a day for reduce risk of infection 6inch trach.Record review of Resident #4's physician orders, dated 06/23/2025, reflected: Monitor trach for placement every shift. Record review of Resident #4's physician orders, dated 08/29/2025, reflected: Monitor trach stoma site for issues including but not limited to: S/S of infection, irritation, redness, swelling, pain, mucosal tissue issues. Notify MD or NP for any findings which are abnormal and complete progress note. every shift for tracheostomy care Notify for abnormal findings and complete progress note. Trach care daily and PRN: For disposable: (Trach Canula size 7.5) remove and dispose of inner cannula. Replace with new inner cannula, gauze, and collar. one time a day for Reduce risk of infection Inner Canula Size [NAME] 7.5. Observation on 08/29/25 at 09:03 AM revealed LVN E collected supplies to perform trach care on Resident #4. LVN E collected supplies from the medication cart such as trach kit and a 10cc vial of normal saline. LVN E donned an isolation gown, a clean gloves without performing hand hygiene. LVN E took clean gauze wiped Resident #4's oxygen mask removing the excess secretions, then wiped Resident #4's left neck and shoulder removing excess secretions. LVN E then reached into her pants pocket with soiled gloved hand and pull a glove out . LVN E then removed gloves from 1 hand, reached in her pants pocket again but did not get anything. LVN E removed gloves from the other hand and walked out to the doorway to get more gloves from her medication cart parked in the doorway. LVN E grabbed more gloves from her medication cart and placed gloves in her pants pocket. LVN E applied clean gloves without hand hygiene, took the yankauer (A Yankauer is a medical suction device used to remove fluids, Residents Affected - Few 455862 Page 28 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood, secretions, and debris from a patient's oral airway or surgical site to prevent aspiration and maintain a clear field for healthcare providers.) and inserted it into Resident #4's trach, suctioning while going in and coming out of the trach. LVN E used water which she took from a normal saline vial (10 cc), put water in a plastic cup which was not sterile to clean the yankauer. LVN E again inserted the yankauer into Resident #4's trach, with the yankauer not being sterile, and again applied suction while going in and coming out. LVN E removed the soiled gloves, no hand hygiene, reached in her pants pocket for clean gloves, nurse applied clean gloves, applied split gauze under Resident #4's trach, did not clean Resident #4's trach stoma, did not change Resident #4's trach tide even though it was saturated with secretions. During an interview on 08/29/2025 at 10:12 a.m., LVN E stated she knew to wash her hands before entering residents' rooms. LVN E stated she could not recall washing her hands before entering Resident #4's room. LVN E stated she knew to sanitize her hands between glove changes but there was not sanitizer in the room. LVN E stated hand hygiene was performed to prevent infection. During an interview on 08/29/2025 at 11:27 p.m., the RDON stated he expected staff to perform hand hygiene before and after any care and between glove changes. The RDON explained it was important to perform hand hygiene to protect themselves and the resident from possible infection issues. The RDON expected staff to follow Trach Care policy and procedure . The RDON stated suctioning was necessary for residents with trachs and she expected suction equipment at the bedside. She expected nurses to apply suction after hyperoxygenation . The RDON stated she expected the nurses to hyperoxygenation the resident before applying suction. She expected the suction to be applied when pulling out of the trach, not when going into the trach . The RDON stated she expected trach care equipment available at bedside for emergency services.Record review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2019, reflected: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread ofinfections to other personnel, residents, and visitors.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readilyaccessible and convenient for staff use to encourage compliance with hand hygiene policies.6.Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:a. When hands are visibly soiled.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial ornon-antimicrobial) and water for the following situations:a. Before and after coming on duty.b. Before and after direct contact with residents.d. Before performing any non-surgical invasive procedures.e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites).f. Before donning sterile gloves.h. Before moving from a contaminated body site to a clean body site during resident care.i. After contact with a resident's intact skin.j. After contact with blood or bodily fluids.k. After handling used dressings, contaminated equipment, etc.l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.m. After removing gloves.n. Before and after entering isolation precaution settings.Record review of the facility's policy titled Infection Control Guidelines, revised August 2012, reflected: PurposeTo provide guidelines for general infection control while caring for residents.General Guidelines1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected orconfirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions,and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucousmembranes.2. Transmission-Based Precautions will be used whenever measures more stringent than StandardPrecautions are needed to prevent the spread of infection.3. Employees must wash their hands for ten (10) to fifteen 455862 Page 29 of 30 455862 09/05/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (15) seconds using antimicrobial or nonantimicrobialsoap and water under the following conditions:a. Before and after direct contact with residents.b. When hands are visibly dirty or soiled with blood or other body fluids.c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin.d. After removing gloves.e. After handling items potentially contaminated with blood, body fluids, or secretions.4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands arenot visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all thefollowing situations:a. Before and after direct contact with residents.b. Before donning sterile gloves.c. Before performing any non-surgical invasive procedures.d. Before preparing or handling medications.e. Before handling clean or soiled dressings, gauze pads, etc.f. Before moving from a contaminated body site to a clean body site during resident care.g. After contact with a resident's intact skin.h. After handling used dressings, contaminated equipment, etc.i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; andj. After removing gloves.5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or bodyfluids or other potentially infectious materials.Record review of the facility's policy titled Personal Protective Equipment-Using Gloves, revised September 2010, reflected: PurposeTo guide the use of gloves.Objectives1. To prevent the spread of infection.Miscellaneous1. When gloves are indicated, use disposable single-use gloves.2. Discard used gloves into the waste receptacle inside the examination or treatment room.3. Use sterile gloves for invasive procedures to prevent contamination of the patient, and to decrease the riskof infection when changing dressings.4. Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providingtreatment or services to the patient and when cleaning contaminated surfaces.5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.)When to Use Gloves1. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin.2. When the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis, etc.3. When cleaning up spills or splashes of blood or body fluids.4. When cleaning potentially contaminated items; and5. Whenever in doubt.Removing Gloves1. Using one hand, pull the cuff down over the opposite hand turning the glove inside out.2. Discard the glove into the designated waste receptacle inside the room.3. With the ungloved hand, pull the cuff down over the opposite hand, turning the glove inside out.4. Discard the glove into the designated waste receptacle inside the room.5. Discard the glove package into a waste receptacle inside the room.6. Wash hands. 455862 Page 30 of 30