Health inspection·December 10, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to extend to the resident representative the right to make decisions on behalf of the resident for 1 of 12 residents (Resident #8) reviewed for resident representative rights. Resident #8 eloped from the facility on 12/5/25 between the period 7:15 p.m. to 7:30 p.m. and the Guardian was not contacted immediately. This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences. The findings include: Record review of Resident #8's face sheet, dated 12/06/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and eloped on 12/5/25 and readmitted [DATE]. Resident #8 diagnoses included: encephalopathy (primary)-stroke, cerebral infarction (stroke), (admitting diagnosis), HTN, lack of coordination, cognitive deficits, acute kidney failure, heart disease, and schizophrenia (mental illness). The RP was listed as: a Guardian. Record review of Resident#8's quarterly MDS, dated [DATE], reflected a BIMS score of 3 indicative of severe impairment in cognition. The ADLs for: B/B was listed as continent. Transfer and Mobility was listed as set-up. ROM: no impairments. Assistive devices: none. Section E - Behavior- none. Wandering was listed as none. Record review of Resident #8's Letters of Guardianship, dated 11/14/25, reflected the state was granted guardianship with a Guardship Agency recognized to accept Resident #8. Record review of Resident# 8's Care Plan, revised 10/7/25 revealed: resident had a goal of elopement/wanderer based on evidenced of impaired safety awareness. Interventions listed included: re-direction and identify pattern of wandering. Record review of Resident #8's incident report dated 12/5/25 at 7:30 p.m., authored by LVN B reflected the resident during rounds at 7:30 p.m. Resident #8 was missing in her room, and a search was started for her; and she was not located. The Administrator, DON family and 911 were notified. [RP/Guardian was not mentioned as notified of the elopement]. Record review of Resident #8's ER report dated 12/8/25 at 10:58 a.m., reflected resident presented as an eloped resident with history of strokes. The resident was found on a bus on 12/8/25. Resident was confused and could not answer questions and explain her whereabouts the last 4 days. Presenting problem was found on bus. Diagnoses assigned to the resident included: stroke, hypertension, and history of stroke with aphasia needing placement. Recommendation: inpatient admission for assessment and future placement in a secure unit. During an observation and interview on 12/9/25 at 1:26 p.m., Resident #8 was in a hospital bed, alert and oriented X3 (person, place, and time). The resident was confused and neutral in her disposition and accepting an interview. Resident #8 stated she eloped from the door left opened by EMS; but could not remember the date and time. Resident # 8 stated she made no efforts to contact family or the Guardian. During a joint interview on 12/6/25 at 8:50 a.m., the Administrator stated and confirmed by the DON that Resident #8 had been missing from the facility on 12/5/25. The DON stated the Resident #8 had Page 1 of 12 455862 455862 12/10/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no family in the state and the nearest family lived in different state. The Administrator stated the resident was last seen at 7:30 PM when her medications had been administered. The Administrator stated the grounds and facility were searched and the resident could not be found. The Administrator stated law enforcement was notified on 12/5/25. The Administrator stated he was not certain of the date and time the RP/Guardian was notified of the incident. During an interview on 12/06/2025 at 11:16 a.m., the DON stated as of 12/06/25 at 11:21 a.m. Resident #8 had not been located; also, law enforcement had not located the missing resident. The DON stated she was familiar with the care of Resident #8. The DON stated the resident's closest family lived in another state. The DON stated she was not certain of the date and time the RP/Guardian was notified of the incident but was certain the RP/Guardian was contacted. During a telephone interview on 12/6/25 at 4:23 p.m., LVN B stated during her rounds at 7:30 p.m. on 12/5/25 she could not locate the resident and called the DON, family, and the Administrator. LVN B stated she did not know how the resident had eloped, and the resident had never shown exit seeking behavior or any negative behaviors. LVN B stated she did not know when the RP/Guardian was notified of the elopement and assumed someone in management would contact the RP/Guardian. LVN B stated she assumed the DON or the Administrator would notify the Guardian. During an interview on 12/06/25 at 4:40 p.m., the Administrator stated he was notified around on 12/05/25 around 8:30 p.m. that Resident #8 had eloped and stated the facility followed its elopement policy. The Administrator stated the policy would include notifying RP/Guardian. The Administrator stated nursing staff was responsible for notifying the Guardian as soon as time permitted. During a telephone interview on 12/07/25 at 10:50 a.m., the on-call Guardianship staff stated the Guardianship Agency was notified on 12/5/25 at 10:30 p.m. by the facility (name not given) [3-hour lapse time] when the resident went missing; and not immediately. The Program Manager stated the resident only had family outside the state. The Program Manager stated the guardianship was granted on 11/14/2025, due to the resident's mild cognitive problems resulting from multiple strokes. During a telephone interview on 12/8/25 at 1:25 p.m., the Program Manager (Guardianship Agency) stated Resident #8 was found on 12/8/25 in the morning by a metro bus driver and taken to the ER at a local hospital by EMS. The Program Manager stated the resident exhibited an altered mental state on the bus and the bus driver called 911. The Program Manager stated the resident was confused and could not provide details about the elopement. The Program Manager stated the resident would be admitted ; and the plan of discharge would be placed in a secure unit. The Program Manager stated the Guardian Agency as the RP was not immediately notified of the elopement incident. The Program Manager stated she was notified on 12/6/25 at 7:52 a.m. by the facility. [The Program Manager may not have been aware the on-call Guardian staff was notified by the facility of the missing resident on 12/5/25 at 10:30 p.m.] During an interview on 12/9/25 at 1:45 p.m., the hospital Case Manager stated the hospital received information that the Guardian was not notified timely of the elopement. The Case Manager stated information revealed that the Guardian was contacted on 12/8/25 and was not aware of the elopement incident involving Resident [#8]. The Case Manager stated the resident was medically stable and could return to the facility. Record review of facility's Change of Condition Policy, revised: 09/2025, read: Purpose To ensure timely recognition, documentation, and reporting of a resident's change in condition to the attending physician, responsible party, and appropriate nursing staff, in compliance with federal and state regulations. Policy Statement It is the policy of this facility to promptly identify and report any significant change in a resident's physical, mental, or psychosocial condition. Staff will notify the DON, physician, and the resident's legal representative or responsible party.Notifications must occur immediately (within one hour of recognition) [highlight added by surveyor] or as soon as the resident 455862 Page 2 of 12 455862 12/10/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0580 is stabilized. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455862 Page 3 of 12 455862 12/10/2025 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, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 12 residents (Resident #8) reviewed for neglect. The facility neglected to follow its process for elopement when they failed to monitor an exit door when the alarm was bypassed by staff during EMS entry/exit. Resident #8 eloped from the facility's Unit 3 vicinity hall 100 door between 7:15 p.m. and 7:30 p.m. on 12/5/25 and was found by law enforcement on a bus on 12/9/25. Resident #8 had severe cognitive impairment, impaired safety awareness, and a history of strokes. An IJ (Immediate Jeopardy) was identified on 12/07/25. The IJ template was provided to the facility on [DATE] at 2:45 p.m. While the immediacy was removed on 12/10/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to further rehearse their elopement procedure and ensure all the door alarms worked. This failure could lead to residents experiencing serious injury, serious harm, serious impairment to include death.The findings include: Record review of Resident #8 's face sheet, dated 12/06/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and eloped on 12/5/25 and readmitted [DATE]. Resident #8 had diagnoses which included: encephalopathy (primary)-stroke, cerebral infarction (stroke), (admitting diagnosis), HTN, lack of coordination, cognitive deficits, acute kidney failure, heart disease, and schizophrenia (mental illness). The RP was listed as: a Guardian. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 3 indicative of severe impairment in cognition. The ADLs for: B/B was listed as continent. Transfer and Mobility was listed as set-up. ROM: no impairments. Assistive devices: none. Section E - Behavior- none. Wandering was listed as none. Record review of Resident #8's Letters of Guardianship dated 11/14/25 reflected the state [state and county name] was granted guardianship with a Guardship Agency recognized to accept Resident #8. Record review of Resident #8's elopement risk dated 7/18/25 reflected score was 9 (low risk for elopement) and no evidence of resident exit seeking prior to the incident. However, R#8 was confused and had to be re-directed when wandering into her previous room in a previous hall. Record review of Resident# 8's Care Plan, revised 10/7/25 revealed: resident had a goal of elopement/wanderer based on evidenced of impaired safety awareness. Interventions listed included: re-direction and identify pattern of wandering. Record review of Resident #8's physician orders, dated December 2025, reflected: Lisinopril Oral Tablet 10 MG (Lisinopril, a high blood pressure medication), once per day for HTN. Record review of Resident #8's MAR, dated December 2025 reflected: resident received her HTN medication and there were no refusals. The record reflected Resident #8 received her medication on 12/5/25 at 09:00 a.m. Record review of Resident #8's incident report dated 12/5/25 at 7:30 p.m., authored by LVN B reflected the LVN made rounds at 7:30 p.m. and could not locate the resident in her room or the facility. Incident report reflected, Resident #8 was missing from her room, and a search was started for her; and she was not located. The Administrator, DON, family and 911 were notified. Record review of Resident #8's photo given to law enforcement on 12/5/25 reflected the following description: [Resident #8] .May or may not have glasses.5'3 [height; feet and inches] .150 lbs.Jeans.no shoes-Hospital socks.Ponytail. Observation on 12/06/25 from 9:55 a.m. to 10:30 a.m. revealed Resident #8 was not found or located in the facility or the grounds of the facility. Observation likewise reflected all 15-second delay exit doors triggered at 8 locations. The 15-second delay system at Unit 3 vicinity hall 100 did not trigger and required a keypad code to open the door. The door alarm did not sound when forced open following a 15-second delay. Observation also 455862 Page 4 of 12 455862 12/10/2025 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 reflected a resident entering the keypad code to the said exit door and left to the backyard. Observation on 12/06/25 at 1:12 p.m., revealed the front door had a sign present to alert visitors not to assist any resident out of the facility and to see nursing staff for any questions. Observation on 12/06/25 at 5:30 p.m. revealed Resident #8's room was about 30 feet from the door EMS used. [Note: the door could only be opened by a code, and it would sound when left open. The door appeared to require repair to allow for the 15-second delay.] [DON during entrance conference expressed the opinion that Resident #8 might have eloped from the door used by EMS on the day of the incident when the door was bypassed and door alarm was not working. The DON stated the EMS were assisted by staff for entry and exit but the door was not monitored during that time.] During a joint interview on 12/06/25 at 8:50 a.m., the Administrator stated and confirmed by the DON that Resident #8 had been missing from the facility on 12/5/25. The DON stated the resident had no family in the state and the nearest family lived in another state. The Administrator stated the resident was last seen at 7:30 PM when her medications had been administered. The Administrator stated the grounds and facility were searched and the resident could not be found. The Administrator stated law enforcement was notified on 12/5/25. The Administrator stated he did not know how or where the resident eloped. Observation on 12/06/25 at 10:00 a.m., Resident #9 entered the code in the keypad for the 15-second delay system in Unit 3 vicinity hall 100 exit door, the same door Resident #8 eloped from, in the presence of the Administrator and exited through the door. The door did not alarm when Resident #9 exited the building because he had entered the keycode to disable the alarm. During an interview on 12/06/25 at 10:00 a.m., the Administrator confirmed the 15-second delay system at Unit 3 vicinity hall 100 exit door did not function because the magnetic system was not connecting and retriggering the alarm after the door was opened and reclosed. Based on the surveyor's observation, when inquired about the unknown resident [Resident #9] entering the keypad code, the Administrator stated the resident had a BIMS of 15 and did not elaborate further. During an interview on 12/06/2025 at 11:16 a.m., the DON stated as of 11:21 a.m. [12/06/25] Resident #8 had not been located; also, law enforcement had not located the missing resident. The DON stated she was familiar with the care of Resident #8. The DON stated the focus of care was around: stroke interventions, HTN, and minimal assistance in ADLs; no assistive devices. The DON stated the resident was not an elopement risk, did not have exit behaviors and did not express a need to leave the facility and was not drug seeking. The DON stated the last time the resident was seen was on 12/06/25 during medication pass by MA C. The DON stated the Guardian and the MD were notified of the missing person. The DON stated there were no risk factors for the elopement. The DON stated the last elopement assessment was done on 12/4/25 and the score was a 6 for low elopement. The DON stated the resident had no falls and the closest family lived in another state. The DON stated she did not know why the resident had a homeless history and the reason for Guardianship; the BIMS score was 3 dated October 2025. The DON stated the resident could have followed emergency staff around 7:15 PM-7:40 PM; an emergency involving resident (11) who was experiencing chest pains. The DON stated she could not give an explanation how the incident occurred. The DON stated the facility became aware of the missing resident around 8:00 p.m. when the nurse (LVN B) began doing rounds. The DON stated alert and oriented residents with high BIM scores were known to have the keypad code to exit doors; but she did not have a list of the residents with keypad codes. When informed by the surveyor that Resident#9 was observed to have used the keypad code to the 15-second delay system, the DON said that the facility would change the codes and not provide codes to residents. Record review of Resident #8's Elopement Risk Evaluation, dated 12/03/2025, reflected a score of 6.0. The risk score was not defined on the evaluation document. Resident #8 was noted as: not bedfast, not on a 455862 Page 5 of 12 455862 12/10/2025 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 secured unit, able to ambulate independently or with a device, understood and verbalized acceptance of need for nursing home care, had independent cognitive skills- her decisions were consistent/reasonable, had made no attempts to leave on her own, was not restless or anxious; and could recognize stop lights and signs, precautions when crossing the street, and state name and location of current residence. During an interview on 12/06/25 at 11:30 a.m., the DON stated the previous management listed every resident as an elopement risk as a standard practice. The DON added the former MDS Nurse (RN D) (last employed 11/02/25) did not fully review MDSs and CPs and only continued what previously existed and changed the date. The DON stated that the elopement assessment done on 12/3/25 for Resident #8 was performed by her and was accurate. The DON stated the MDS was not accurate, and the SW was fired for inaccurate assessments. The DON added the BIMS should have been in the moderate range (6-12). The DON stated that updating the CPs and MDSs was a work in progress by the new management team. The DON stated the new company took over on 10/26/25. The DON stated she started work on 10/28/25 and the Administrator started 10/26/25. During an observation and interview on 12/06/25 at 1:57 p.m., revealed Resident #10, roommate to Resident #8, was in the dining hall, sitting in a W/C, alert and oriented to person and location. The resident stated she could not remember when she physically saw Resident #8. Resident #10 stated Resident #8 was not exit seeking, was not delusional or hallucinating. Resident #10 added that Resident #8 was safe and comfortable in the facility. Resident #8, per Resident #10, had not been abused or neglected. During an interview on 12/06/25 at 2:08 p.m., LVN E stated she was familiar with the care provided to Resident #8; and care included assessment and medications. The LVN E stated the resident revealed no signs or symptoms of elopement or being in distressed. LVN E stated the elopement may have occurred when the resident followed someone; and the resident did not require monitoring. LVN E stated the resident preferred to stay in her room and better monitoring, especially during an emergency involving residents, could have helped. LVN E stated the elopement training included rounding and searching for a resident. LVN E stated she was not aware Unit 3 vicinity hall 100 exit door was not functioning properly. During an interview on 12/06/2025 at 2:20 p.m., MA F stated they: last saw the resident when MA C gave medications for cholesterol to the resident. The resident was not in distress or exit seeking. The medication was given to the resident in her room. MA F stated the resident had never been exit seeking or complained about the facility. MA F stated the facility may not have fully monitored the resident. MA F stated the facility's attention may have shifted to the emergency involving Resident #11 who was having chest pains around 7:15 p.m., the ambulance arrived around 7:30 p.m. MA F stated she had no idea why and how the resident eloped. MA F stated she did not monitor the exit door used by EMS because she participated in an emergency involving Resident #11. MA F stated she had received training on elopement, and the highlight was to search for a missing resident. MA F stated she was not aware Unit 3 vicinity hall 100 exit door was not functioning properly. During an interview on 12/6/25 at 2: 25 p.m., MA C stated : she was hired 12/5/25 and was assigned to give medications to Resident #8; the medication given was Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium). The resident was in her bed watching TV; and no S/S of exit seeking fear, hallucinations/delusions. The resident accepted the medication and the MA C left. MA C was trained in elopement and part of the training included searching for the resident. MA C stated she responded to an emergency involving Resident #11. MA C stated she had no idea why and how Resident #8 eloped. MA C stated she did not monitor the exit door used by EMS because she participated in an emergency involving Resident #11. MA C stated she was not aware Unit 3 vicinity hall 100 exit door was not functioning properly. Record review of Resident #11's Nurse Note dated 12/0/5/25 at 7:15 p.m. authored by RN A reflected: she responded to Resident #11's chest pain and 455862 Page 6 of 12 455862 12/10/2025 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 called EMS. During an interview on 12/06/25 at 2:45 p.m., the Administrator stated he did not have a list of residents who had the codes to the keypad system exit doors. The Administrator stated the keypad codes would all be changed today (12/6/25) and no residents would be permitted to have the codes. During an interview on 12/06/25 at 3:24 p.m., LVN G stated: she provided care to Resident #8 which included medication management, vitals, and monitoring. LVN G stated the resident was always calm in disposition but would have moments of confusion. For example, the LVN G stated the resident at times would wander to unit 200 to return to her old room in unit 200 and would be re-directed. LVN G stated the resident was ambulatory and independent and was oriented towards person and place. LVN G stated the resident never revealed signs of exit seeking or any negative behaviors; the resident was calmed. LVN G stated she was trained in elopement, and the highlight was to monitor exit seeking residents. LVN G stated she was not aware Unit 3 vicinity hall 100 exit door was not functioning properly. During an interview on 12/06/25 at 3:48 p.m., CNA H stated that she last saw the resident at 6:40 p.m. in her room sitting in bed watching TV, not anxious or in distress. The CNA H stated when she entered the resident's room the resident gave her a hug and said she was [NAME]. CNA H stated the resident was never exit seeking and never displayed any negative behaviors. CNA H stated the resident eat ate her meal without any difficulties or concerns. The CNA could not explain why the resident suddenly eloped. The CNA H stated the resident might have eloped during the emergency time that the staff was treating another resident. The CNA H stated the resident never, never was exit seeking. The CNA H stated the resident was ambulatory and at times was confused and would be re-directed. The CNA stated she was trained in elopement. CNA H stated she was not aware Unit 3 vicinity hall 100 exit door was not functioning properly. During a telephone interview on 12/6/25 at 4:10 p.m., the NP on call stated she was notified by a text message on 12/6/25 at 9:15 a.m. about the missing resident. The only order the NP gave was to call 911. During a telephone interview on 12/6/25 at 4:23 p.m., LVN B stated: during her rounds at 7:30 p.m. she could not locate the resident and called the DON, family, and the Administrator. LVN B stated nursing shift was from 6:00 p.m. to 6:00 a.m. and she came on shift at 6:00 p.m. LVN B stated she did not know how the resident eloped, and the resident had never shown exit seeking behaviors or any negative behaviors. LVN B stated she did not know what additional measures the facility could have implemented except for closer monitoring of the exit door when there was an emergency in the facility between 7:00 p.m. to 7:30 p.m. LVN B stated she was trained on elopement prevention. LVN B stated she was not aware Unit 3 vicinity hall 100 exit door was not functioning properly. During an interview on 12/06/25 at 4:40 p.m., the Administrator stated: he was notified around 8:30 p.m. about the elopement of Resident #8. The Administrator stated the facility followed its elopement policy. The Administrator stated the resident was still missing as of 12/06/25 at 4:46 p.m. The Administrator stated he had no clue as to the reason or how the resident eloped. The Administrator added, the resident was not exit seeking and showed no S/S of distress, fear, safety concerns, and or hallucinations/delusions to account for the elopement. During an interview on 12/7/25 at 10:20 a.m., the DON stated the update submitted to HHS on 12/06/25 at, 12:54 PM was correct and the resident has had not been located as of 12/7/25 at 10:32 a.m. The DON stated law enforcement would not do a Silver Alert [statewide wide alert for an elderly person missing] because Resident #8 did not meet criteria. The DON stated she did not know the criteria for Silver Alert. The DON stated she gave a photo with descriptive items to law enforcement when law enforcement became involved in the incident 12/5/25 around 9:30 p.m. The DON stated she interviewed the staff present during the EMS arrival on 12/5/26 and none of the staff had seen the resident elope. The DON stated during an emergency it took priority (response to a resident having chest pains) over someone monitoring 455862 Page 7 of 12 455862 12/10/2025 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 exit door used by EMS. During a telephone interview on 12/07/25 at 10:50 a.m., the on-call Guardianship staff stated the Guardianship Agency was notified on 12/5/25 at 10:30 p.m. [3-hour lapse time] when the resident went missing; and not immediately. The on-call Guardianship staff stated the resident only had family outside the state. of Texas. The on-call Guardianship staff stated the guardianship was granted on 11/14/2025, due to the resident's mild cognitive problems resulting from multiple strokes. During a telephone interview on 12/8/25 at 1:25 p.m., the Program Manager (Guardianship Agency) stated Resident #8 was found 12/8/25 in the morning by a bus driver and taken to the ER at a local hospital by EMS. The Program Manager stated the resident exhibited an altered mental state on the bus and the bus driver called 911. The Program Manager stated the resident was confused and could not provide details about the elopement. The Program Manager stated the resident would be admitted ; and the plan of discharge would be placed in a secure unit. The Program Manager stated the Guardian Agency as the RP was not immediately notified of the elopement incident. The Program Manager stated she was notified on 12/6/25 at 7:52 a.m. by the facility. Record review of Resident #8's EMS report dated 12/8/25 [a.m.] revealed: .911 contacted by [bus company name] bus driver for a ‘lady that's been on the bus since 0600, doesn't known where she's going, and started shaking'. The EMS report reflected that the resident was confused and could not answer questions; she had on multiple jackets and two long sleeve shirts. The EMS report added that the resident was hypertensive. Record review of weather history [https://weatherspark.com/h/td/8004/Historical-Weather-in-[NAME]-Texas-United-States-Today] for the city the nursing facility was located, on 12/05/25- 12/08/25, revealed: the temperature was 48.9 F (Fahrenheit )at 06:53 p.m. and 48.0 F at 07:53 p.m. on 12/05/25, during the time the resident allegedly eloped. The temperatures on 12/06/25 ranged from 42.1 F at 07:53 a.m. and 77.0 F at 02:53 p.m. The temperatures on 12/07/25 ranged from 46.9 F at 06:53 p.m. and 73.0 F at 12:53 p.m. The temperatures on 12/08/25 ranged from 35.1 F at 06:63 a.m. to 50.0 F at 11:53 a.m. Record review of Resident #8's ER report dated 12/8/25 at 10:58 a.m., reflected resident presented as an eloped resident with history of strokes. The resident was found on a bus on 12/8/25. The resident was confused and could not answer questions and explain her whereabouts the last 4 days. Presenting problem was found on bus. Diagnoses assigned to the resident included: stroke, hypertension, and history of stroke with aphasia (language disorder), needing placement. Recommendation: inpatient admission for assessment and future placement in a secure unit. During an interview on 12/9/25 at 12:05 p.m., the Administrator stated the facility would accept the return of Resident #8 and place her on 1:1 pending a placement in a secured unit at another NF (nursing facility). The Administrator stated the resident at time of elopement was Medicaid pending and it would be difficult to place until the Medicaid situation had been resolved. During an observation and interview on 12/9/25 at 1:26 p.m., revealed Resident #8 was in a hospital bed, alert and oriented X3. The resident did not have visible bruises, skin tears, or injuries present. The resident was confused and neutral in her disposition and accepted an interview. Resident #8 stated she eloped from the door left unsecured and unmonitored by EMS; but could not remember the date and time. Resident #8 stated no staff was monitoring the exit door, and she decided to leave the facility. Resident #8 stated she did not know why she left, she did not hear voices and there was no abuse or neglect present. Resident #8 stated she had no coat, and it was cold the days she was outside the facility. Resident #8 did not remember where she ate, drank water, or sought shelter. Resident #8 stated she missed taking her medications. To stay warm, Resident # 8 stated she rode buses, but could not remember whether she had money. Resident #8 was accepting of returning to the NF. Resident #8 stated she made no efforts to contact family or the Guardian. Resident #8 stated that no harm of injury was experienced during the 3 days she was out of the 455862 Page 8 of 12 455862 12/10/2025 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 facility. Resident #8 added that the thoughts she experienced outside the facility in the cold weather was that I was fine. Resident #8 remembered she had no coat and was dressed in a gown, had shoes, and a shirt. Resident #8 stated the elopement was not planned and she did not know why she exited the opened exit door not monitored by staff. The resident stated, I just decided to leave.I just walked out. Resident #8 stated she had not planned or eloped from the facility prior to the incident on the day the door was left open. During an interview on 12/9/25 at 1:45 p.m., the Hospital Case Manager stated: Resident #8 was confused and alert and oriented to herself when assessed in the ER on [DATE] at 10:58 a.m. The Hospital Case Manager stated the facility at first did not want to accept the return of the resident because they could not meet the needs of a resident who had eloped and needed to be in secured unit. However, the Hospital Case Manager stated the facility accepted the return of the resident on 12/9/25 around 1:06 p.m. Hospital Case Manager stated the resident was admitted to the hospital for her safety and assessment; and the resident was known to have a diagnosis of multiple strokes. The Hospital Case Manager stated the hospital felt that the facility neglected the resident by not monitoring and the resident eloping for 4 days. The Hospital Case Manager stated the hospital received information that the Guardian was not notified timely of the elopement. The Hospital Case Manager stated information revealed that the Guardian was contacted on 12/8/25 and was not aware of the elopement incident involving the Resident [#8]. The Hospital Case Manager stated the resident was medically stable and could return to the facility. Telephone interview on 12/10/25 at 2:34 p.m., with the facility's Director of Business Development, stated he visited the hospital on [DATE] and informed the Hospital Case Manager the facility could not accept the resident because she was an elopement risk, and the facility did not have a secure unit or a wander guard system. He stated that on 12/9/25 the facility accepted the transfer of the resident and would put her on 1:1 until placement in a secure unit. Record review of Resident #11's Nurse Note dated 12/0/5/25 at 7:15 p.m. authored by RN A reflected: she responded to Resident #11's chest pain and called EMS. Record review of Census document, dated 12/04/2025, reflected a total resident census of 70. Record review of facility document titled and dated 12-4-25 reflected a list of 70 resident names with risk scores and risk level. Resident #8 was noted on the document with a score of 6.0 and risk level as low risk. Record review of the facility's Logbook documentation dated 12/05/25 (time not given) revealed all eight 15-second alarm doors and keypad were checked and pass. [Doors were not check prior to 12/5/25] Record review of the facility's Logbook Documentation of the alarm system reflected the last documented entry was on 6/26/25 for 8 exits. Record review of the facility's Abuse and Neglect policy dated 10/2025 reflected that Prevention Measures included Training on Prohibiting and preventing all forms of abuse, neglect and exploitation. Record review of the facility's Elopement Prevention &response Policy, undated, revealed: .The facility will: Protect residents identified as being a risk for elopement.Conduct regular assessments to identify risk factors.Implement interventions to prevent elopement.Environmental Controls.All exit doors will have functioning alarms and be checked each shift.Outdoor areas (courtyards, patios) must be secured and monitored. Record review of facility's Sign-In/Sigh-Out policy dated 10/2025 revealed: .Residents must be signed out at the nurse's station or designated location when leaving the facility, regardless of duration or destination. Their nurse must be notified that they are leaving. Record review of facility's Change of Condition Policy dated Revised: 09/2025, revealed: Purpose To ensure timely recognition, documentation, and reporting of a resident's change in condition to the attending physician, responsible party, and appropriate nursing staff, in compliance with federal and state regulations. Policy Statement It is the policy of this facility to promptly identify and report any significant change in a resident's physical, mental, or 455862 Page 9 of 12 455862 12/10/2025 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 psychosocial condition. Staff will notify the DON, physician, and the resident's legal representative or responsible party.Notifications must occur immediately (within one hour of recognition) [highlight added by surveyor] or as soon as the resident is stabilized. During an interview on 12/7/25 at 2:45 p.m., the Administrator was notified of the Immediate Jeopardy (IJ) and the IJ template was provided to the Administrator. The following Plan of Removal submitted by the facility was accepted on 12/10/25 at 5:54 p.m. It was documented as follows: [Nursing Home]PLAN OF REMOVAL F600 12/07/20251. Immediate Corrective ActionsResident #8 The facility received notification at 11:00 AM on 12/08/2025 that Resident #8 had been located alive and unharmed. The resident was taken to the emergency room for evaluation and HHS Guardian, and law enforcement. After hospital stabilization, the resident will be readmitted today 12/09/2025 to a room across from the nurse's station for better monitoring. We will be doing one-to-one supervision for a period of five days to assure her safety and ensure no further elopement tendencies are recognized. With her readmission we will consider her elopement risk factor at risk due to this event. The assigned guardian has agreed to the readmission and has asked to continue networking for a placement in a secured unit. Upon completion of the 5-day monitoring, we will implement a 30-minute check procedure with nursing to document her presence. Activities/meal attendance will be completed with an escort.2. Immediate Facility Safety ActionsExit Door Security All exit doors were immediately checked at 5 PM on 12/07/2025 by Maintenance. All alarms were confirmed operational and documented.Staffing During EMS Entry/Exit Effective immediately, any EMS arrival requires a dedicated staff member posted at the door to maintain supervision during the entire EMS presence in the building.Census Verification A full resident headcount was completed by the DON at 5 PM on 12/07/2025. No other residents were missing or unaccounted for.Immediate Staff Re-Education On 12/07/2025 at 5 PM, all on-duty staff were re-educated on:o Elopement Prevention Policyo Door-monitoring requirements during emergencieso Exit codes will not be shared with residents nor visitors.o Random competency quizzes will be completed weekly for 4 weeks.Enhanced Door Monitoring Beginning 12/08/2025, staff will complete:o Daily exit door audits for 2 weeks (12/08-12/21).o Weekly exit door audits thereafter.3. Identification of At-Risk Residents On 12/04/2025, the DON reviewed elopement risk assessments for all residents, including Resident #8. The resident was assessed on 07/02/25 with the results showing a low risk. None were assessed as having moderate or high elopement risk at this timeFacility-wide Staff Retraining Full staff retraining on elopement procedures, supervision, and emergency response will begin on 12/08/25 with completion on 12/09/2025 for active personnel. Other staff such as PRN [as needed] or those on leave will occur prior to their return to the facility. The DON/designee will manage this retraining. The Administrator will monitor for completion. Environmental Controls Weekly maintenance audit of all door alarms for 8 weeks, then monthly.4. Monitoring to Ensure Ongoing ComplianceAdministrator/DON Monitoring Audit 100% of:o EMS entry/exit logso Door monitoring logso Elopement assessments Daily audits for 2 weeks, then weekly for 6 weeks.Mock Elopement Drills Weekly mock elopement drills for 8 weeks. QA [Quality Assurance] Oversight All audits and drill results will be reviewed in weekly Standards of Care meeting for 8 weeks.Any deviations will result in immediate corrective action 12/09/2025-12/10/2025 Verification of POR F600 Observations: Observation on 12/09/2025 at 06:58 p.m. reflected Resident #8 was on one-to-one monitoring with a CNA I in the room. Observation on 12/10/2025 at 12:37 p.m. reflected Resident #8 was on one-to-one monitoring with DA J in the room. During an observation and interview on 12/10/2025 from 09:26 p.m. to 09:43 p.m. reflected all twelve (12) 15-second delay exit doors sounded when opened without a keypad code entered. All doors were observed to be capable of opening by the 15-second delay method, 455862 Page 10 of 12 455862 12/10/2025 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 but the alarm would sound. The Maintenance Director stated the logbook entry he was completing to document door checks only listed 8 doors; however, the facility had a total of 12 exit doors. The Maintenance Director stated he was checking all 12 doors during door checks. The Unit 3 vicinity hall 100 door was observed to function properly, the door alarmed when forced open without a keypad code entered and the alarm reactivated immediately upon closure, during the door check on 12/10/2025. During an observation on 12/10/2025 at 10:35 a.m., a mock elopement drill was initiated by the DON, calling a code pink. Staff were observed to respond to code, and staff were assigned areas to search. At 10:40 a.m. staff were alerted the resident was located and at 10:41 a.m., the DON stated, code pink was all clear.Interviews: During an interview on 12/09/2025 at 06:58 p.m., CNA I stated he was providing monitoring for Resident #8. During an interview on 12/10/2025 at 12:37 p.m., DA J stated she was assigned to monitor Resident #8 continuously, not leave Resident #8 unattended, due to Resident #8's elopement incident. DA J indicated the Q30 minute monitoring log next to her chair and stated the log was to be completed for each monitoring session. During interviews with 35 of 99 staff listed on staff roster on 12/10/2025 from 09:45 a.m. to 04:14 p.m., the following staff reported they received recent elopement training and were able to demonstrate knowledge per the facility policy for elopement response, knew what code pink represented, and how to respond and document when EMS staff were entering/leaving the facility:10 administrative staff1 DON1 RN of 54 LVNs of 12 (2 from 7 AM- 7 PM shift, 1 from 7 PM to 7 AM shift, and 1 PRN)3 MAs of 11 (1 from 6 AM-2 PM shift, 1 from 2 PM-10 PM shift, and 1 PRN)1 Restorative Aide of 16 CNAs (2 f 455862 Page 11 of 12 455862 12/10/2025 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 observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 6 (Resident #1) residents reviewed, in that: There was no physician order for the use of the continuous positive airway pressure machine for Resident #1. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings were: Record review of Resident #1's face sheet dated 12/4/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: chronic obstructive pulmonary disease (a lung condition that makes breathing hard due to inflamed, narrowed airways), bipolar disorder (a disorder causing extreme mood shifts), and generalized anxiety disorder (a mental health condition marked by excessive, uncontrollable worry about various everyday things). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating intact cognition. Record review of Resident # 1's Quarterly MDS , dated 11/1/2025 , revealed under section O : Special Treatments , Procedures,and Progams use of continuous positive airway pressure machine . Record review of Resident #1's progress notes for 11/17/2025 at 1239 p.m; revealed RN (A) entered the resident's room to check the resident's continuous positive airway pressure machine. Record review of Resident # 1's care plan, dated 11/11/2025, revealed a care plan with interventions use continuous positive airway machine at night. Record review of Physician monthly orders for November 2025 did not reveal orders for a continuous positive airway pressure machine. Record review of the hospital discharge summary for Resident #1, dated 11.7.2025, revealed orders for a continuous positive airway pressure machine at bedtime. Interview with RN (A) on 12/4/2025 at 2 PM revealed that she had previously cared for Resident #1 and confirmed Resident #1 used a continuous positive airway pressure machine. She was unaware of why there was no physician order for the constant positive airway pressure machine. During an interview and observation with Resident #1 on 12/5/2025 at 10:44 a.m., Resident #1 confirmed that she is on a continuous positive airway pressure machine but could not recall for how long .Observed revealed a constant positive airway pressure machine at bedside. During an interview with the DON on December 5, 2025, at 11:10 a.m., the DON made it clear that all resident clinical records, including physician orders, must be complete and accurate. She stated that the discharge and subsequent re-admission of Resident #1 may have resulted in the order being overlooked and not reactivated. The DON, who has been in her role for 30 days, acknowledged that she has not yet had the opportunity to audit orders for all Residents. She emphasized the admitting nurse missed the physician's order for a constant positive airway pressure machine. She said moving forward, she will audit physician orders for all Residents weekly for 30 days, and quality management will conduct audits at random. Record review of the facility policy, medication and treatment orders, dated 2001, revealed that drug and biological orders must be recorded on the physician's order sheet in the residents' chart 455862 Page 12 of 12