Health inspection·May 5, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to designate an RN to serve as DON on a full-time basis in that: Residents Affected - Few The facility had no full time DON from 04/14/23 through present [05/05/23]. This failure could place all residents at risk for not receiving necessary care and services. Findings included: An interview on 05/05/23 at 11:45 AM with the ADON revealed she was an LVN. She stated there was no DON at the facility since 04/14/23. The ADON stated RCRN typically came to the facility at least once a week and accomplished DON related tasks. She said RCRN was also available for consultation over the phone anytime. The ADON said currently in the absence of a DON at the facility she consults RCRN when any nursing management issues occurred. Interview on 05/05/23 at 12:10PM with the RCRN who was present at the facility during the investigation revealed the facility had not employed a DON since 04/14/23. She stated they had been trying to hire someone for the DON position but had not been successful at this time. RCRN said since there was no full time DON at the facility, she was covering the facility as much as possible. She stated as she had three other facilities to supervise, she was unable to be on site all the time however made a point to visit this facility at least once a week. RCRN said the days when she was not onsite, she was available over the phone anytime of the day. During an interview on 05/05/23 at 12:45PM the Administrator (ADM) stated the facility did not employ a DON since the last DON left the facility's employment on 04/14/23. She said the facility hired another candidate on 04/03/23 however did last only till 04/12/23 and the facility was trying to recruit a DON ever since. The ADM stated few interviews were scheduled starting from 05/05/2023. When the investigator asked how the facility was managing without a DON, the ADM stated there are two or more experienced full time RNs who work as charge nurses and were capable of addressing most of the nursing management decision making. She said the facility already had RCRN as back up at any point of time, also could get the help of MDS nurse if necessary. When the investigator asked if the absence of a full time DON posed any risk to the residents, the ADM stated she did not feel that way as RNs or RCRN were available to the staff all the time, on site or on call for accomplishing the duties of the DON until a new full time DON was recruited. During an interview on 05/05/23 at 1:45pm RN A stated she was working at the facility for more than three years and this was the first time there was no DON at the facility. When the investigator Page 1 of 3 675914 675914 05/05/2023 Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758

F 0727 Level of Harm - Minimal harm or potential for actual harm asked who she would consult for DON related issues in the absence of a full time DON, she stated the ADM was there always for help. RN A said the RCRN also was available anytime either on site or on call. Record review on 05/05/23 of EDON's personnel file reflected that she was hired on 05/02/22 and her last day of work at the facility as DON was on 04/14/23. Residents Affected - Few Record review on 05/05 23 of the facility policy Director of Nurses revised in August 2006 reflected: The Nursing Services department is under the direct supervision of a Registered Nurse. 1.The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. 2.The Director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. Developing and periodically updating the nursing service objectives and statements of philosophy. b. Developing standards of nursing practice. c. Developing and maintaining nursing policy and procedure manuals. d. Developing and maintaining written job descriptions for each level of nursing personnel. e. Scheduling of daily rounds to visit residents. f. developing methods for coordination of nursing services with other resident services. g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident. h. Developing staff training programs for nursing service personnel. I. Participating in the planning and budgeting for Nursing Services. j. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care. k. Assessing the nursing requirements for each resident admitted and assisting the Attending Physician in planning for the resident's care. l. Participating in the development and implementation of the resident assessment (MDS) and comprehensive care plan. m. Establishing resident selection criteria for determining which residents may be fed by paid 675914 Page 2 of 3 675914 05/05/2023 Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758

F 0727 feeding assistants; and Level of Harm - Minimal harm or potential for actual harm n. Assuring that nursing care personnel are administering care and services in accordance with the resident's assessment and care plan. Residents Affected - Few 675914 Page 3 of 3