Health inspection·September 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report Resident #1's injury of unknown origin to the SSA. Staff observed Resident #1 had discoloration to his buttocks area on 09/10/25. Staff confirmed Resident #1's discoloration was an acute (sudden) femur (thigh) fracture on 09/11/25. This failure could place residents at risk of untreated medical problems, worsening injuries, mental anguish, and reduced quality of life. Findings included:Review of Resident #1's admission Record, dated 09/18/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included bilateral (both sides) primary osteoarthritis (a chronic, degenerative condition characterized by the progressive breakdown of joint cartilage and underlying bone) of hip, pain in left and right hip, age-related osteoporosis (the condition of bones becoming weak and brittle), schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder), vascular dementia (a type of dementia that happens when blood vessels in the brain are damaged or blocked), muscle weakness, lack of coordination, and cognitive communication deficit. Resident #1 was discharged to the hospital on [DATE]. Review of Resident #1's Annual MDS Assessment, dated 09/11/25, reflected a BIMS of 3/15, which indicated he had severe cognitive impairment.Review of Resident #1's Care Plan, last revised 08/07/25, reflected he had potential for complications related to schizophrenia and bipolar disorder and was at risk for falls. Review of Resident #1's Progress Notes reflected:-A note created by the ADON on 09/11/25 at 6:45 a.m., Writer was called to room d/t resident c/o pain, while repositioning resident in bed for brief change. Writer noted dark discoloration to left buttock area.NP on call notified. New order: Left lateral hip x-ray stat (immediately) confirmation. DON and Guardian notified.-A note created by RN A on 09/11/25 at 7:33 p.m., Resident was transferred out to hospital per order.MPOA was called and notified. DON aware. Review of Resident #1's Radiology Results, dated 09/11/25 at 10:36 a.m., reflected he was x-rayed and had a mild displaced comminuted right proximal femoral (thigh) fracture. Review of Resident #1's Physician Note, dated 09/11/25, reflected, He was evaluated per nursing request following complaints of right hip pain with movement. Per nursing report, [Resident #1] verbalized pain during repositioning in bed for a brief change .On exam, dark discoloration was noted over the left buttock area. A stat right hip x-ray was ordered, which revealed an acute mildly displaced comminuted fracture of the right proximal femur. [Resident #1 denied any recent fall or trauma, and no recent falls have been reported or documented. The ADON, DON, and facility Administrator were notified for further investigation.[Resident #1] was Page 1 of 13 455862 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sent to the emergency department for further evaluation and management. Review of Resident #1's Medical Provider Progress Note, dated 09/16/25, reflected Resident #1 presented to the hospital from the facility after a mechanical fall. The fall occurred on 09/11/25 and resulted in a right intertrochanteric area of the femur. During an interview on 09/18/25 at 10:32 a.m., the ADON stated the day before Resident #1 was sent to the hospital (09/10/25), CNA B notified her that she observed Resident #1 had dark purple discoloration to his left buttocks and experienced pain when she turned him. The ADON stated she also made the same observation as CNA B during her assessment of Resident #1 and notified the DON, who informed her to notify the on-call NP. The ADON stated the on-call NP ordered a stat x-ray on Resident #1's left hip area on 09/10/25 and the results on 09/11/25 revealed he had a right hip fracture. The ADON stated she notified the on-call NP and DON of the results and sent Resident #1 to the hospital per on-call NP orders. The ADON stated Resident #1's right hip fracture was an injury of unknown origin because the facility did not know how he sustained the discoloration and fracture. The ADON stated the ADM was responsible for immediately reporting injury of unknown origin to the SSA. The ADON stated she knew it was important to report injury of unknown origin to the SSA and said, To investigate and make sure resident safety and determine how incident occurred. Residents could be at risk of neglect I would say. During an interview on 09/18/25 at 10:57 a.m., CNA B stated she observed Resident #1 had purple colored bruise on his left buttocks when she was changing his brief and repositioning him in bed last week (09/10/25). CNA B stated she notified the ADON of Resident #1's bruise. CNA B stated Resident #1's left buttocks bruise was an injury of unknown origin because the facility did not know how he sustained the bruise. CNA B stated the nurses and DON were responsible for immediately reporting injury of unknown origin to the SSA. CNA B stated she knew it was important to report injury of unknown origin to the SSA and said, Because the reason is really important. Someone has to report that so it won't happen again. Residents could be at risk of getting more sick and stop walking if not immediately reported.During an interview on 09/18/25 at 12:39 p.m., the DON stated the ADON told her on 09/10/25 that Resident #1 complained of pain, the ADON assessed Resident #1 and observed he had a bruise. The DON stated she instructed the ADON to notify the doctor and order an x-ray. The DON stated the ADON or RN A told her that Resident #1's mobile x-ray results reflected he had a fracture. The DON stated she instructed the ADON or RN A to notify the NP. The DON stated Resident #1's bruise and fracture was an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The DON stated she expected her staff to notify the ADM if there was any injury of unknown origin. The DON stated her and the ADM were responsible for reporting injury of unknown origin to the SSA. The DON stated she believed the timeframe for submitting injury of unknown origin reports to the SSA was within two hours. The DON stated the CEO oversaw to ensure her and the ADM reported injury of unknown origin to the SSA. The DON stated she informed the ADM of Resident #1's injury of unknown origin. The DON stated she did not report and did not know why she did not report Resident #1's injury of unknown origin to the SSA. The DON stated she knew it was important to report injury of unknown origin to the SSA and said, So that if it is possible abuse, it doesn't reoccur. Residents could be at risk of death and a multitude of things. During an interview on 09/18/25 at 2:20 p.m., the NP stated he reviewed Resident #1's x-ray results, found he had an acute femur fracture, and ordered him to be sent to the hospital for further evaluation and treatment on 09/11/25. The NP stated he also observed Resident #1 had blue, yellow and purple colored bruises on his left buttocks on 09/11/25. The NP stated Resident #1's bruises and fracture could be an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. During an interview on 09/18/25 at 3:33 p.m., RN A stated the ADON told her on 455862 Page 2 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/11/25 that CNA B notified her during the night of 09/10/25 that Resident #1 was moaning and groaning when CNA B was providing care. RN A stated Resident #1's mobile x-ray results revealed on 09/11/25 that he had a right hip fracture. RN A stated Resident #1's fracture was an injury of unknown origin because the facility did not know how he sustained the fracture. RN A stated the ADM was responsible for reporting injury of unknown origin to the SSA. RN A stated she knew it was important to report injury of unknown origin to the SSA and said, So they can do appropriate and immediate investigation to see what happened. Residents could be at risk of abuse and neglect and also for their safety. During an interview on 09/18/25 at 5:17 p.m., the ADM stated she was not notified that Resident #1 had a bruise on his buttocks. The ADM stated the surveyor's interview was the first time she was hearing Resident #1 had a bruise on his buttocks. The ADM stated Resident #1's bruise on his buttocks was an injury of unknown origin because the facility did not know how he sustained the bruise. The ADM stated she expected staff to notify her and the DON if there was an injury of unknown origin. The ADM stated she was responsible for reporting injury of unknown origin to the SSA within two hours. The ADM stated the DON and CEO were responsible for ensuring she reported injury of unknown origin to the SSA. The ADM stated she knew it was important to report injury of unknown origin to the SSA and said, To rule out ANE and make sure residents were cared for and to ensure whoever caused harm was dealt with. Residents could be at risk of death, harm, and neglect. Review of the facility's in-services, April-September 2025, reflected none related to reporting injuries of unknown origin to facility management and the SSA.Review of the facility's Reporting Abuse to Facility Management policy, revised December 2024, reflected, Policy Statement: It is the responsibility or our employees, facility consultants, Attending Physician, family members, visitors etc to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management.Policy Interpretation and Implementation:g. Injury of unknown source is defined as an injury that meets both of the following conditions:(1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and(2) The injury is suspicious because of: the extent of the injury; or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or the number of injuries observed at one particular point in time; or the incidence of injuries over time.Review of the facility's Long Term Care Regulation Provider Letter, issued 08/29/24, reflected, A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: suspicious injuries of unknown origin.Do Report: An incident that results in serious bodily injury that involves any of the following: injuries of unknown source immediately, but not later than two hours after the incident occurs or is suspected. Injuries of unknown source: Note: an injury should be classified as an injury of unknown source when ALL of the following conditions are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of: the extent of the injury; or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or the number of injuries observed at one point in time; or the incidence of injuries over time. 455862 Page 3 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have evidence that all alleged violations are thoroughly investigated for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to initiate and complete a thorough investigation of Resident #1's injury of unknown origin. Staff observed Resident #1 had discoloration to his buttocks area on 09/10/25. Staff confirmed Resident #1's discoloration was an acute (sudden) femur (thigh) fracture on 09/11/25. An IJ was identified on 09/18/25. The IJ template was provided to the facility on [DATE] at 7:10 p.m. While the IJ was removed on 09/21/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of untreated medical problems, worsening injuries, mental anguish, and reduced quality of life. Findings include:Review of Resident #1's admission Record, dated 09/18/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included bilateral (both sides) primary osteoarthritis (a chronic, degenerative condition characterized by the progressive breakdown of joint cartilage and underlying bone) of hip, pain in left and right hip, age-related osteoporosis (the condition of bones becoming weak and brittle), schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder), vascular dementia (a type of dementia that happens when blood vessels in the brain are damaged or blocked), muscle weakness, lack of coordination, and cognitive communication deficit. Resident #1 was discharged to the hospital on [DATE]. Review of Resident #1's Annual MDS Assessment, dated 09/11/25, reflected a BIMS of 3/15, which indicated he had severe cognitive impairment. Resident #1 required substantial/maximal assistance with transfers. Review of Resident #1's Care Plan, last revised 08/07/25, reflected he had potential for complications related to schizophrenia and bipolar disorder and was at risk for falls. Review of Resident #1's Progress Notes reflected:-A note created by the ADON on 09/11/25 at 6:45 a.m., Writer was called to room d/t resident c/o pain, while repositioning resident in bed for brief change. Writer noted dark discoloration to left buttock area.NP on call notified. New order: Left lateral hip x-ray stat (immediately) confirmation. DON and Guardian notified.-A note created by RN A on 09/11/25 at 7:33 p.m., Resident was transferred out to hospital per order.MPOA was called and notified. DON aware. Review of Resident #1's Radiology Results, dated 09/11/25 at 10:36 a.m., reflected he was x-rayed and had a mild displaced comminuted right proximal femoral (thigh) fracture. Review of Resident #1's Physician Note, dated 09/11/25, reflected, He was evaluated per nursing request following complaints of right hip pain with movement. Per nursing report, [Resident #1] verbalized pain during repositioning in bed for a brief change .On exam, dark discoloration was noted over the left buttock area. A stat right hip x-ray was ordered, which revealed an acute mildly displaced comminuted fracture of the right proximal femur. [Resident #1 denied any recent fall or trauma, and no recent falls have been reported or documented. The ADON, DON, and facility Administrator were notified for further investigation.[Resident #1] was sent to the emergency department for further evaluation and management. Review of Resident #1's Medical Provider Progress Note, dated 09/16/25, reflected Resident #1 presented to the hospital from the facility after a mechanical fall. The fall occurred on 09/11/25 and resulted in a right intertrochanteric area of the femur. During an interview on 09/18/25 at 10:32 a.m., the ADON stated the day before Resident #1 was sent to the hospital (09/10/25), CNA B notified her that she observed Resident #1 had dark purple discoloration to his left buttocks and experienced pain when she turned him. The ADON stated she also made the same observation as CNA B during her assessment of Resident #1 Residents Affected - Few 455862 Page 4 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and notified the DON, who informed her to notify the on-call NP. The ADON stated Resident #1 told her that he fell and could not elaborate on the incident. The ADON stated the on-call NP ordered a stat x-ray on Resident #1's left hip area on 09/10/25 and the results on 09/11/25 revealed he had a right hip fracture. The ADON stated she notified the on-call NP and DON of the results and sent Resident #1 to the hospital per on-call NP orders. The ADON stated Resident #1's right hip fracture was an injury of unknown origin because the facility did not know how he sustained the discoloration and fracture. The ADON stated the ADM was responsible for investigating injury of unknown origin. The ADON stated she knew it was important to investigate injury of unknown origin and said, To investigate and make sure resident safety and determine how incident occurred. Residents could be at risk of neglect I would say. During an interview on 09/18/25 at 10:57 a.m., CNA B stated she observed Resident #1 had a purple bruise on his left buttocks when she was changing his brief and repositioning him in bed last week (09/10/25). CNA B stated she notified the ADON of Resident #1's bruise. CNA B stated Resident #1's left buttocks bruise was an injury of unknown origin because the facility did not know how he sustained the bruise. CNA B stated the nurses and DON were responsible for investigating injury of unknown origin. CNA B stated she knew it was important to investigate injury of unknown origin and said, Because the reason is really important.so it won't happen again. Residents could be at risk of getting more sick and stop walking .During an interview on 09/18/25 at 12:39 p.m., the DON stated the ADON told her on 09/10/25 that Resident #1 complained of pain, the ADON assessed Resident #1 and observed he had a bruise. The DON stated she instructed the ADON to notify the doctor and order an x-ray. The DON stated the ADON or RN A told her that Resident #1's mobile x-ray results reflected he had a fracture. The DON stated she instructed the ADON or RN A to notify the NP. The DON stated Resident #1's bruise and fracture was an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The DON stated she expected her staff to notify the ADM if there was any injury of unknown origin. The DON stated her and the ADM were responsible for investigating injury of unknown origin. The DON stated the CEO oversaw to ensure her and the ADM investigated injury of unknown origin. The DON stated she informed the ADM of Resident #1's injury of unknown origin on 09/11/25. The DON stated she did not investigate and did not know why she did not investigate Resident #1's injury of unknown origin. The DON stated she knew it was important to investigate injury of unknown origin and said, So that if it is possible abuse, it doesn't reoccur. Residents could be at risk of death and a multitude of things. During an interview on 09/18/25 at 2:20 p.m., the NP stated he reviewed Resident #1's x-ray results, found he had an acute femur fracture, and ordered him to be sent to the hospital for further evaluation and treatment on 09/11/25. The NP stated he also observed Resident #1 had blue, yellow and purple colored bruises on his left buttocks on 09/11/25. The NP stated Resident #1's bruises and fracture could be an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The NP stated he expected the facility staff to thoroughly investigate Resident #1's incident and determine the likely source and cause of the injury and said, If there were bruises, obviously something happened. The NP stated he believed Resident #1's acute femur fracture was indicative of some kind of trauma to that area of his body. The NP stated Resident #1's incident would have kicked off an investigation and did not know why there was not an initiated investigation. During an interview on 09/18/25 at 3:33 p.m., RN A stated the ADON told her on 09/11/25 that CNA B notified her during the night of 09/10/25 that Resident #1 was moaning and groaning when CNA B was providing care. RN A stated it was not typical for Resident #1 to moan and groan on the night of 09/10/25. RN A stated Resident #1's mobile x-ray results revealed on 09/11/25 that he had a right hip fracture. RN A stated Resident #1's fracture was an 455862 Page 5 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few injury of unknown origin because the facility did not know how he sustained the fracture. RN A stated the ADM was responsible for investigating injury of unknown origin. RN A stated she knew it was important to investigate injury of unknown origin and said, So they can do appropriate and immediate investigation to see what happened. Residents could be at risk of abuse and neglect and also for their safety. During an interview on 09/18/25 at 5:17 p.m., the ADM stated she was not notified that Resident #1 had a bruise on his buttocks. The ADM stated the surveyor's interview was the first time she was hearing Resident #1 had a bruise on his buttocks. The ADM stated Resident #1's bruise on his buttocks was an injury of unknown origin because the facility did not know how he sustained the bruise. The ADM stated she expected staff to notify her and the DON if there was an injury of unknown origin. The ADM stated her and the DON were responsible for investigating injury of unknown origin. The ADM stated the CEO was responsible for ensuring her and the DON investigated injury of unknown origin. The ADM stated she knew it was important to investigate injury of unknown origin and said, Because there might be others who might be at harm's way and might be at risk of harm to those harming them. Review of the facility's Abuse Investigations policy, revised December 2024, reflected, Policy Statement:All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management.Policy Interpretation and Implementation:1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.17. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services.The ADM was notified on 09/18/25 at 7:13 p.m. that an IJ had been identified and an IJ template was provided. The following POR was approved on 09/20/25 at 1:50 p.m.: POR Immediate Jeopardy Failure to Investigate Alleged Violations The facility failed to have evidence that all alleged violations were thoroughly investigated.On 9/18/25 at 7:10 p.m. the surveyors determined that the facility was in Immediate Jeopardy due to: Facility failed to report an injury of unknown origin in accordance with State and Federal regulations.Resident#1 was discharged to hospital on 9/11/25 and remains in the hospital .Immediate interventions when notified of IJ are the following: On 9/18/25, the Administrator and DON were in-serviced by contracted consultant regarding investigation and timely reporting of any injury of unknown origin within 2 hours of receiving report of incident. The facility's policy and procedures regarding reporting abuse, neglect and exploitation was reviewed and explained in detail by a contracted consultant on 9/18/25. Included in this training was the course of action that must be taken anytime an alleged abuse, neglect or exploitation allegation is made. Both DON and Administration demonstrated understanding of policy and procedures by verbalizing understanding and signing the acknowledgement on an in-service document. A flow chart was provided by consultant to DON and administrator as visual aid in facilitating reporting to resident for any injuries. All findings were reported to the DON and Administrator. All nursing staff, including new hires, current full-time, PRN, agency nursing staff, were in-serviced by DON/designee on 9/18/25, 9/19 and 9/20 on identifying and reporting requirements for injuries of unknown origin. All nursing staff, including new hires, current full-time, PRN and agency staff, were given a T/F test regarding investigating and reporting injuries of unknown origin. Administrator and DON will discuss with IDT members during our daily morning meeting and stand down meeting all findings and will ensure compliance is met and ServicesTargeted Audience - Interdisciplinary Team The surveyor monitored the POR on 09/20/25 as followed: During interviews from 09/20/25 at 3:15 455862 Page 6 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few p.m. through 09/20/25 at 4:55 p.m., LVN F, RN A, LVN G, CNA H, CNA I, CNA J, and LVN L stated they were in-serviced and provided competency before their shifts by the DON/designee on identifying and immediately reporting requirements for injuries of unknown origin. They knew to immediately notify the ADM, DON, and Charge nurse. They also completed skin sweeps to assess each resident for any new injuries. During an interview on 09/21/25 at 12:15 p.m., the DON stated her and the ADM were in-serviced by the contracted consultant on reporting and investigating injuries of unknown origin within two hours of receiving report of the incident. The DON stated her and the signed an acknowledgement of the in-service received to demonstrate understanding the facility's policy and procedures. The DON stated her and the ADM received a flow chart as a visual aid in facilitating reporting to the SSA. The DON stated skin sweeps were completed by designated nurses to assess each resident for injuries and there were no abnormal findings reported to her and the ADM. The DON stated staff were also in-serviced and tested for competency on identifying and reporting requirements for injuries of unknown origin. The DON stated her and the ADM will discuss with IDT members during daily meetings all findings to ensure compliance was met and sustained. Review of the facility's In-Services, 09/18/25-09/20/25, reflected the ADM and DON were reeducated by a contracted consultant on reporting and investigating injuries of unknown origin within two hours of receiving report of the incident. The ADM and DON signed an acknowledgement of the in-service received. Staff were also in-serviced and tested for competency by the DON/designee on identifying and reporting requirements for injuries of unknown origin. Review of the facility's Reporting Abuse, Neglect, and Exploitation policy, reviewed on 09/18/25, reflected the policy was reviewed and explained in detail by the contracted consultant. A flow chart was provided as a visual aid for the ADM and DON in facilitating reporting to the SSA. Review of the facility's Skin Assessments completed by the DON and other charge nurses, 09/18/25-09/20/25, reflected all 70 residents were assessed and did not have injuries of unknown origin. The ADM was notified on 09/21/25 at 1:18 p.m. that the IJ had been removed. While the IJ was removed, the facility remained at a scope level of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. 455862 Page 7 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remains free of accident hazards and each resident receives adequate supervision for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to monitor and supervise Resident #1, who was cognitively impaired and a fall risk. Resident #1 complained of pain and had discoloration to his buttocks area on 09/10/25. Resident #1 sustained an acute (sudden) femoral (thigh) fracture and was sent to the hospital for surgery on 09/11/25. An IJ was identified on 09/18/25. The IJ template was provided to the facility on [DATE] at 7:10 p.m. While the IJ was removed on 09/21/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of untreated medical problems, worsening injuries, mental anguish, and reduced quality of life.Findings included:1.Review of Resident #1's admission Record, dated 09/18/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included bilateral (both sides) primary osteoarthritis (a chronic, degenerative condition characterized by the progressive breakdown of joint cartilage and underlying bone) of hip, pain in left and right hip, age-related osteoporosis (the condition of bones becoming weak and brittle), schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder), vascular dementia (a type of dementia that happens when blood vessels in the brain are damaged or blocked), muscle weakness, lack of coordination, right eye blindness, and cognitive communication deficit. Resident #1 was discharged to the hospital on [DATE]. Review of Resident #1's Annual MDS Assessment, dated 07/07/25, reflected a BIMS of 3/15, which indicated he had severe cognitive impairment. Resident #1 had no falls since his admission. Resident #1 also required substantial/maximal assistance with chair/bed-to-chair transfers. Review of Resident #1's Care Plan, last revised 08/07/25, reflected he had potential for complications related to schizophrenia and bipolar disorder and was at risk for falls related to vision. Staff were required to follow the facility's fall protocol. Resident #1 also required 2-person assistance. There was no notes related to mechanical lift assistance with Resident #1's transfers. Review of Resident #1's Progress Notes reflected:-A note created by the ADON on 09/11/25 at 6:45 a.m., Writer was called to room d/t resident c/o pain, while repositioning resident in bed for brief change. Writer noted dark discoloration to left buttock area.NP on call notified. New order: Left lateral hip x-ray stat (immediately) confirmation. DON and Guardian notified. -A note created by RN A on 09/11/25 at 7:33 p.m., Resident was transferred out to hospital per order.MPOA was called and notified. DON aware. There were no documented notes related to an accident/incident before Resident #1 complained of pain and staff observed the discoloration to his buttocks before 09/11/25. Review of Resident #1's skin observation, pain level, and change in condition assessments, dated 09/11/25, reflected they were a system error and the documents were incomplete. Review of Resident #1's Radiology Results, dated 09/11/25 at 10:36 a.m., reflected he was x-rayed and had a mild displaced comminuted right proximal femoral (thigh) fracture. Review of Resident #1's Physician Note, dated 09/11/25, reflected, He was evaluated per nursing request following complaints of right hip pain with movement. Per nursing report, [Resident #1] verbalized pain during repositioning in bed for a brief change .On exam, dark discoloration was noted over the left buttock area. A stat right hip x-ray was ordered, which revealed an acute mildly displaced comminuted fracture of the right proximal femur. [Resident #1 denied any recent fall or trauma, and no recent falls have been reported or documented. 455862 Page 8 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The ADON, DON, and facility Administrator were notified for further investigation.[Resident #1] was sent to the emergency department for further evaluation and management. Review of Resident #1's Medical Provider Progress Note, dated 09/16/25, reflected Resident #1 presented to the hospital from the facility after a mechanical fall. The fall occurred on 09/11/25 and resulted in a right intertrochanteric area of the femur.2. Review of Resident #2's admission Record, dated 09/18/25, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses including muscle weakness, repeated falls, lack of coordination, cognitive communication deficit, and unsteadiness on feet. Review of Resident #2's Quarterly MDS, dated [DATE], reflected a BIMS score of 15/15, which indicated he was cognitively intact. During an interview on 09/18/25 at 10:32 a.m., the ADON stated the day before Resident #1 was sent to the hospital (09/10/25), CNA B notified her that she observed Resident #1 had dark purple discoloration to his left buttocks and experienced pain when she turned him during perineal care. The ADON stated she also made the same observation as CNA B during her assessment of Resident #1. The ADON stated she did not believe Resident #1 had any accidents or incidents before her and CNA B's observation on 09/10/25. The ADON stated Resident #1 told her that he fell and could not elaborate on the incident . The ADON stated she notified the DON, who instructed her to conduct a skin assessment report and notify the on-call NP. The ADON stated she did not complete the skin assessment and that it should have been completed. The ADON stated the on-call NP ordered a stat x-ray on Resident #1's left hip area. The ADON stated the x-ray results revealed on 09/11/25 that Resident #1 had a right hip fracture. The ADON stated she notified the on-call NP and DON of Resident #1's x-ray results and the on-call NP instructed her to send Resident #1 out to the hospital. The ADON stated Resident #1's right hip fracture and discoloration was an injury of unknown origin because the facility did not know how he sustained the discoloration and fracture. The ADON stated CNAs and nurses were responsible for following the facility's fall protocol if a severely cognitive resident reported they fell and had a new skin issue. The ADON stated CNAs and nurses were also expected to notify the ADM, DON, and NP of the alleged incident. The ADON stated her and the DON were responsible for overseeing and ensuring staff followed fall protocol. The ADON stated she knew the importance of following fall protocol and said, To ensure resident safety, to assess the resident and see if the resident had any injuries, and to monitor resident for change in condition. If the fall protocol were not followed, resident could be at risk of neglect.During an interview on 09/18/25 at 10:57 a.m., CNA B stated she observed Resident #1 had a purple bruise on his left buttocks when she was changing his brief and repositioning him in bed last week (09/10/25) during perineal care. CNA B stated Resident #1 told her that he fell in the morning and evening of 09/10/25 and no one listened to him. CNA B stated Resident #1 could not elaborate on the incident. CNA B stated she notified the ADON. CNA B stated Resident #1's left buttocks bruise was an injury of unknown origin because the facility did not know how he sustained the bruise. CNA B stated the CNAs were expected to notify the nurse and ADM if a severely cognitive resident reported they fell and had a new skin issue. CNA B stated nurses were expected to follow the facility's fall protocol if a severely cognitive resident reported they fell and had a new skin issue. CNA B stated the DON was responsible for overseeing and ensuring staff followed fall protocol. CNA B stated she knew the importance of following fall protocol and said, It's a resident's right. We are supposed to care about them. We need to literally report the incident right away. Residents could be at risk of getting hurt and something else could happen to them.During an interview on 09/18/25 at 12:23 p.m., Resident #1's RP stated the ADON notified her on 09/11/25 that Resident #1 had a fracture that was caused by an unwitnessed fall. The RP stated the ADON did not elaborate on how Resident #1's unwitnessed fall occurred. During an 455862 Page 9 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interview on 09/18/25 at 12:39 p.m., the DON stated the ADON told her on 09/10/25 that Resident #1 complained of pain, the ADON assessed Resident #1 and observed he had a bruise. The DON stated she instructed the ADON to notify the doctor and order an x-ray. The DON stated she notified the ADM. The DON stated she could not figure out how Resident #1 sustained the bruise and explained Resident #1 was a mechanical lift transfer. The DON stated the ADON told her that Resident #1 told her that he ended up on the floor on 09/10/25. The DON stated the ADON or RN A told her that Resident #1's mobile x-ray results reflected Resident #1 had a fracture. The DON stated she instructed the ADON or RN A to notify the NP. The DON stated Resident #1's bruise and fracture was an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The DON stated she expected her staff to notify her and the ADM, start clinical duties, such as taking vitals, initiating and conducting neurological monitoring, and notifying the resident's physician, RP and family, and immediately follow the facility's fall protocol if a severely cognitive resident reported they fell and had a new skin issue. The DON stated she was responsible for overseeing and ensuring staff followed the facility's fall protocol. The DON stated she did not know if her staff followed the facility's fall protocol. The DON stated she knew the importance of following fall protocol and said, So you don't end up with injuries. So you don't have poor resident outcomes. Residents could be at risk of pain, decreased quality of life, and including death.During an interview on 09/18/25 at 1:11 p.m., Resident #2 stated he was Resident #1's roommate. Resident #2 stated Resident #1 was blind. Resident #2 stated he observed staff mostly transfer Resident #1 using 1-person assistance and sometimes 2-person assistance. Resident #2 stated he believed it was possible a staff member helped Resident #1 off the floor if he fell. Resident #2 stated staff picked up and turned Resident #1 and did not think staff used a Hoyer lift for Resident #1 during transfers. During an interview on 09/18/25 at 2:20 p.m., the NP stated he reviewed Resident #1's x-ray results, found he had an acute femur fracture, and ordered him to be sent to the hospital for further evaluation and treatment on 09/11/25. The NP stated he was not notified of any incidents/accidents involving Resident #1 before 09/11/25. The NP stated Resident #1 might be able to get up on his own. The NP stated he also observed Resident #1 had blue, yellow and purple colored bruises on his left buttocks on 09/11/25. The NP stated Resident #1's bruises and fracture could be an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The NP stated he expected the facility staff to thoroughly investigate Resident #1's incident and determine the likely source and cause of the injury and said, If there were bruises, obviously something happened. The NP stated he expected the facility staff to follow the facility's fall protocol, initiate and conduct ongoing neurological monitoring, and perform physical assessments if a severely cognitive resident reported they fell and had a new skin issue. The NP stated he was not notified by the ADON that Resident #1 told her that he fell. The NP stated he believed Resident #1's acute femur fracture was indicative of some kind of trauma to that area of his body. The NP stated he was not notified that Resident #1's Medical Provider Progress Notes reflected Resident #1 had a mechanical fall. The NP explained emergency medical services might have been told Resident #1 had a mechanical fall by the facility staff. The NP defined mechanical fall and said, Falling from bed, wheelchair or Hoyer lift, or any other piece of equipment. During interviews on 09/18/25 from 3:03 p.m. through 3:26 p.m., CNA C and MA D stated Resident #1 was a 2-person Hoyer lift transfer. During an interview on 09/18/25 at 3:33 p.m., RN A stated the ADON told her on 09/11/25 that CNA B notified her during the night of 09/10/25 that Resident #1 was moaning and groaning when CNA B was providing care. RN A stated it was not typical for Resident #1 to moan and groan on the night of 09/10/25. RN A stated Resident #1's mobile x-ray results revealed on 09/11/25 that he had a 455862 Page 10 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few right hip fracture. RN A stated Resident #1's fracture was an injury of unknown origin because the facility did not know how he sustained the fracture. RN A stated she would follow the facility's fall protocol and document the incident and notify reporting parties if a severely cognitive resident reported they fell and had a new skin issue. RN A stated the ADON and DON were responsible for overseeing and ensuring nurses followed the facility's fall protocol. RN A stated she knew the importance of following fall protocol and said, So we don't get anything left out. So we have it on record of incident, interventions done, and always good to do fall incident report. Resident could be at risk of more serious injury. During an interview on 09/18/25 at 5:17 p.m., the ADM stated she was not notified that Resident #1 had a bruise on his buttocks last week (09/10/25). The ADM stated the surveyor's interview was the first time she was hearing Resident #1 had a bruise on his buttocks. The ADM stated Resident #1's bruise on his buttocks was an injury of unknown origin because the facility did not know how he sustained the bruise. The ADM stated she expected staff to notify her and the DON if there was an injury of unknown origin. The ADM stated her and the DON were responsible for investigating injury of unknown origin. The ADM stated the CEO was responsible for ensuring her and the DON investigated injury of unknown origin. The ADM stated she knew it was important to investigate injury of unknown origin and said, Because there might be others who might be at harm's way and might be at risk of harm to those harming them. The ADM stated she expected staff to check residents' care plans for their transfer status and said, That's where it needs to be documented. It's important to follow the care plan because it's a care plan for a reason and could cause injury to the resident if not followed. The DON must train CNAs to look at care plan and follow care plan notes for transfer status. The ADM stated it was not acceptable for nurses to give transfer status information to CNAs. The ADM stated the CNAs should be looking at residents' EMR and the DON should be educating the CNAs on transfer status search and task performance. During interviews on 09/18/25 from 4:20 p.m. through 4:49 p.m., CNA C, RN A and MA D stated Resident #1 was a Hoyer lift because they were verbally told by a former nurse who was employed at the facility that he required the Hoyer lift for transfers and were told that anyone who cannot bear any weight were automatically a Hoyer lift. They also stated they looked at Resident #1's EMR and the previous Hoyer lift list that was no longer used to determine Resident #1's transfer status. They knew it was important to know a resident's transfer status for security and to prevent injuries because residents could be at risk for injury or skin tear. Review of the facility's In-Services, 08/01/25-09/18/25, reflected none related to fall protocol, transfers, and accidents/incidents. Review of the facility's Change in a Resident's Condition or Status policy, revised December 2010, reflected staff were required to notify the RP and physician of accidents or incidents involving the resident. Review of the facility's Accidents: Assessment, Management and Interventions policy, undated, reflected, Policy: It is the policy of facility to complete a fall risk assessment for all residents upon admission, readmission, quarterly, after every fall and significant change and as needed. Purpose: To ensure that all residents are properly assessed and appropriate interventions are put place to prevent falls.Procedure: .10. All interventions must be indicated on the falls care plan and on the CNA nursing instructions in EMR. Review of the facility's Assessing Falls and Their Causes policy, revised March 2018, reflected, Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.Steps in the Procedure: After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If 455862 Page 11 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few there is evidence of injury, provide appropriate first aide and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. 6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising.and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. Defining Details of Falls:1. After an observed or probable fall, clarify the details of the fall.2. For each individual, distinguish falls in the following categories.Identifying Causes of a Fall or Fall Risk: 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident.3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found.6. If the cause if unknown by no additional evaluation is done, the physician or nursing staff should note why (e.g., workup already done, finding a cause would not change the approach, etc ). The ADM was notified on 09/18/25 at 7:13 p.m. that an IJ had been identified and an IJ template was provided. The following POR was approved on 09/20/25 at 1:54 p.m.: PORImmediate Jeopardy - Safe Environment Requires Nursing Facilities environment to be free of accident hazards, and for residents to receive adequate supervision and necessary assistance devices to prevent accidents. On 9/18/25 at 7:10 p.m. the surveyors determined that the facility was in Immediate Jeopardy due to: Facility failed to ensure the resident environment remained as free of accident hazards as possible and provide adequate supervision to prevent accidents. Resident #1 on 9/11/25 was discharged to the hospital and remains in the hospital. Immediate interventions when noti?ed of IJ are the following: All Nursing Staff including all new hires, current full-time, PRN, or agencynurse/aides, will be in serviced prior to initiating their shift by current DON/designee regarding utilizing Kardex in Point Click Care as a guide for resident's care needs. DON/designee will demonstrate to these staff members how to access and utilize the Kardex system. The DON/ designee will then require each nursing member to provide a return demonstration on how to access and interpret the Kardex system. An audit was completed on all residents regarding their transfer status. The facility currently has a total of 20 residents requiring a 2-person Hoyer lift transfer. Audit also completed on transfer ability on every resident's care plan and Kardex to ensure accuracy. A skin assessment was completed by DON and other charge nurses to ensure all 70 residents do not have injuries of unknown origin. There were no injuries of unknown origin found. Transfer check-off utilizing gait belt and Hoyer lift methods with all nursing staff including all new hire nursing staff, current full-time, PRN and agency will be completed by physical therapy personnel/designees. No nursing staff, including new hires, full-time, PRN or agency staff members will report to their shift until they have been successfully checked off. Returned demonstration is being provided by all fulltime, new hires, PRN, and agency nurses and aides. Kardex will be printed out and placed at each nurse's station for access should the computer system go down. When change in condition and transfer level changes, the Kardex will be updated by MDS Nurse/Designee. Any changes that a resident may experience causing a status change in their transferring ability will be immediately reported to the DON or designee for immediate care plan and Kardex updating.DON, MDS Nurse and administrator will audit care plans and Kardex weekly for 455862 Page 12 of 13 455862 09/21/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few consistency and accuracy x's 3 months. This process will be reviewed monthly in the QAPI meeting for of Nursing Services Targeted Audience - IDT team The surveyor monitored the POR on 09/20/25 as followed:During interviews from 09/20/25 at 1:58 p.m. through 4:55 p.m., CNA E, LVN F, RN A, LVN G, CNA H, CNA I, CNA J, the MDS Nurse, the ADON, LVN K, and LVN L stated they were in-serviced and provided return demonstrations before their shifts by the DON/designee on accessing and utilizing residents' EMR and physical records at the nursing station as a guide for resident care needs. They also knew the MDS nurse updated residents' EMR and physical records. They also knew any change in residents' condition was to be immediately reported to the DON or designee. They also completed skin assessments to ensure all resident did not have injuries of unknown origin. They also completed transfer checkoffs and return demonstrations of utilizing gait belt and Hoyer lift methods with physical therapy personnel/designees. During observations from 09/21/25 at 9:30 a.m. through 09/21/25 at 9:45 a.m., CNA M, CNA N, and CNA O utilized residents' EMR and proper gait belt and Hoyer lift transfer techniques during resident transfers. During an interview with the DON on 09/21/25 at 12:15 p.m., she stated in-services staff before their shifts regarding utilizing residents' EMR as a guide for residents' care needs and demonstrated how to access and utilize the system. The DON stated she then had each staff member provide a return demonstration on how to access and interpret the system. The DON stated she and the other charge nurses completed skin assessments to ensure all 70 residents did not have injuries of unknown origin. The DON stated her, the MDS Nurse, and the ADM were auditing residents' care plans and Kardex weekly for consistency and accuracy for the next three months and reviewing monthly in QAPI for compliance and sustainability. Review of the facility's In-Services, 09/18/25-09/20/25, reflected the DON/Designee educated and demonstrated to staff on accessing and utilizing residents' EMR as a guide for residents' care needs. Review of the facility's Audit of Residents' Care Plans and EMR, 09/18/25-09/20/25, reflected residents were assessed on their transfer ability and were ensured to be accurate. There were 20 residents who required a Hoyer lift 2-person transfer. Review of the facility's Skin Assessments, 09/18/25-09/20/25, completed by the DON and other charge nurses reflected all 70 residents were assessed and did not have injuries of unknown origin. Review of the facility's Transfer Checkoffs, 09/18/25-09/20/25, utilizing Gait Belt and Hoyer lift methods completed by physical therapy personnel/designees reflected all staff successfully checked off and returned demonstration of techniques before reporting to their shift. Review of Kardex's at each nursing station reflected residents' EMR were available should the computer system go down. Review of the Audit Care Plans and Kardex reflected it was consistently and accurately reviewed weekly and monthly for compliance and sustainability by the DON, MDS Nurse, ADM and QAPI. The ADM was notified on 09/21/25 at 1:18 p.m. that the IJ had been removed. While the IJ was removed, the facility remained at a scope level of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. 455862 Page 13 of 13