Health inspection·November 18, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #2's care plan focus dated 09/24/28 and revised on 03/21/22 for ADL self-care performance deficit related to cognitive deficit, debility and required assist from staff for ADL care, mobility and was apt to refuse care from staff. Review of facility reported incident dated 11/14/24 reflected, The resident was noted in hallway seated in wheelchair. As Administrator approached, the resident pointed to a staff member and said, This is the one that beat me. Upon assessment, some discoloration and slight swelling was noted to the tip of the 5th digit of the resident's right hand. The area was tender to touch. The resident denied pain, other than when the area was touched, and the resident was able to actively move the digit. No open areas, bleeding, or other signs of injury were noted. When asked, upon interview, how the injury occurred, the resident offered various conflicting statements including: It was an accident. I don't know how it happened. I had a confrontation in the shower last night with B-E-A-R. When she washed my hair, my finger got in the way somehow. I don't know how this happened to my finger. I could have caught it in my wheelchair (demonstrating placing her hands on the outer rings of the wheels of her wheelchair and self-propelling). Review of Resident #2's progress notes for 11/14/24 reflected no entry for the self-reported injury of an unknown origin. Review of Resident #3's Face sheet, undated, reflected a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with a diagnosis of arteriosclerotic heart disease (a condition where plaque buildup in the arteries of the heart) and muscle wasting. Review of Resident #3's quarterly MDS assessment, dated 10/11/24, reflected a BIMS score of 15, no cognitive impairment. Review of Resident #3's care plan focus dated 10/27/15 and revision on 10/03/22 reflected Resident #3 was at risk for decreased cardiac tissue perfusion relate history of CAD (coronary artery disease), hypertension (high blood pressure), and hyperlipidemia (abnormally high levels of lipids of fats in the blood). Goal dated 11/26/21, revision, 01/17/24 monitor blood pressure and heart rate as ordered/indicated, notify medical doctor of abnormal findings. Review of #3's order summary, undated, document all vital signs (measures of a person's basic bodily functions, typically including body temperate, pulse rate, respiratory rate (breathing) and blood pressure) complete every shift. Review of Resident #3's treatment administration record for 10/30/24 and 10/31/24 for the first nursing shift reflected blood pressure, temperature, pulse, and respiratory rate N/A (not applicable). During an interview on 11/18/24 at 12:55 PM, the SW stated documentation in general was important to get a clear picture and anyone should be able to go into a resident's chart and see what was going on with them. The ADM stated she expected nurses to document changes in condition, incidents, complains, voiced pain, and unwitnessed injuries. She stated it was the nurses responsibility to ensure incidents were documented in resident charts. The ADM stated a negative outcome of documentation not being thorough could be the failure for communication to get passed on or the staff could fail to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brush Country Nursing and Rehabilitation 6500 Brush Country Rd Austin, TX 78749 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 assess or follow the resident . Level of Harm - Minimal harm or potential for actual harm During an interview on 11/18/24 at 1:46 PM, the LVN TN confirmed Resident #3's medical administration record reflected N/A (not applicable) for 10/30/24 and 10/31/24 for Resident #3's blood pressure, temperature, pulse, and respiratory rate. She stated if blood pressure readings were not recorded accurately, residents' blood pressure readings could be high, the resident might be agitated, and there might be a non-addressed reason for resident hospitalization. Residents Affected - Some During an interview on 11/14/24 at 2:59 PM, the Corporate RN stated Resident #2's incident of an injury of unknown cause on 11/14/24 should have been entered in a progress note because if things were not documented there could be a lack of follow up care. He stated he did believe that there was follow up care even though the event from 11/14/24 was not documented in Resident #2's progress notes. Review of the facility's undated Charting and Documentation Policy reflected the following: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical chart. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. . 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675118 If continuation sheet Page 3 of 3