Inspection·December 11, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and oriented x3, history of falls (1-2 falls in the last 3 months), balance problems while standing, decreased muscle coordination/jerking movements, changes in gait pattern, and required use of assistive device (i.e. cane, walker, wheelchair) were marked.Review of Resident #1's progress notes and EMR items from 10/29/25 through 12/10/25 reflected no information for a documented wheelchair assessment indicating it was evaluated for functionality or safety. In an observation and interview on 12/10/25 at 11:07 AM with Resident #1 in his room, he stated he had a concern with his wheelchair brakes not being functional. At this time, Resident #1 was in bed and surveyor observed Resident #1's wheelchair at bedside in the locked position. Surveyor observed and tested the brakes on the wheelchair; the brakes on the right side of the wheelchair while engaged had a good grip and prevented the right wheel from moving when putting slight pressure on the chair to move it. The left side of the wheelchair was also tested and with the left brake engaged the chair easily moved revealing that the left brake was not functioning correctly. The break mechanism and handle itself also appeared slightly loose. Resident #1 stated that it has been over a month that the break was non-functional. He stated he alerted 3 staff but could not recall who he notified other than the DOR who he also notified earlier that day 12/10/25, but had not yet been resolved. Resident #1 stated that at times he did self-transfer before assistance arrived, and it scared him to not have functional brakes because the wheelchair could move backwards which could cause him to fall. Resident #1 denied that he had a fall or an injury directly related to the wheelchair break not being operational. In an interview on 12/10/25 at 11:10 AM with CNA A, she stated she did not know Resident #1's wheelchair brake was not functional and she could not recall the last time it was checked. She stated she would assist Resident #1 with transferring from his bed to his wheelchair, but he has been known to do transfers himself before help arrived. She stated that a negative outcome of not having functional brakes would be Resident #1 could have a fall and injure himself. In an interview on 12/10/25 at 12:56 PM with RN B, she stated she was the nurse for Resident #1. She stated she was not aware that Resident #1's wheelchairs brakes were not functional. RN B stated Resident #1 had an unsteady gait, diabetic ulcers, which contributed to the unsteady gait, and was also known to be impatient when asking for assistance; he would frequently do self-transfers. RN B stated Resident #1's weakness is primarily affecting the left side of the body. RN B stated that if a resident is on the falling star program, it means they are at risk for falls. She stated things that could contribute to falls included weakness, behavior, pain, and a non-functional wheelchair could also contribute. RN B stated when they are aware a wheelchair is not functioning they will alert maintenance and PT. RN B denied having any knowledge of the non-functional wheelchair and denied Resident #1 ever alerting her of it. RN B stated it was important for Resident #1 to have a safe and functional wheelchair to prevent a fall on the floor when he completes transfers himself. In an interview on 12/10/25 at 01:23 PM with DOR, she stated the falling star program was used to identify residents who were at risk for falls or have had falls in the past. The DOR stated she worked with Resident #1, and he was a fall risk and has had falls in the past. DOR stated she spoke to Resident #1 that morning and was alerted to his wheelchair brakes not being functional and advised him that she would pass the message along to OT during his appointment later in the day so OT could take a look at the wheelchair. DOR stated the wheelchair Resident #1 was using was a wheelchair that was provided to him by the facility. She stated she did not know the last time it was checked to determine it was fully functional and would have to refer surveyor to OT (OT C specifically). DOR stated that a negative outcome of Resident #1's brakes not working was the potential for him to have a fall if he tried to transfer himself to or from the chair. In an interview on 12/10/25 at 01:42 PM with OT C, stated she worked with Resident #1. She stated she was alerted by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676095 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 676095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Oaks Nursing and Rehabilitation Center 3200 W. Slaughter Lane Austin, TX 78748 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DOR that Resident #1 had concerns with his wheelchair brakes, and that he was on schedule to be seen that day at 2pm. OT C stated she had a session with Resident #1 the day before on 12/09/25, and that while doing OT his wheelchair did not shift backwards but stated she did not specifically assess it at the time for functionality. OT C stated Resident #1 had a lot of left sided knee pain, difficulty pivoting, and was a fall risk. OT C stated that equipment is evaluated regularly by the therapy department to ensure it is safe and functional but could not recall the last time Resident #1's wheelchair was evaluated. OT C stated a negative outcome of Resident #1's brakes not working would be that it could contribute to a fall. OT C stated Resident #1 was seen by PT 10/14/25 through 11/25/25 and was being seen by OT presently with 12/10/25 being his fourth visit. She stated she reviewed notes and documentation for that period of time which did not reflect Resident #1's wheelchair had been assessed to ensure the brakes were functional. In an interview on 12/10/25 at 01:57 PM with ADON, she stated the falling star program was for residents who were at risk for falls. ADON stated that it was the responsibility of the therapy department to ensure residents' equipment such as wheelchairs were monitored for safety and functionality. She stated if direct care staff were to notice equipment was not working or brakes were not functional, while working with the resident, it was her expectation that the therapy department was alerted to have it fixed. She stated a negative outcome of Resident #1 not having functional brakes was the potential for him to have a fall if he were to self-transfer. The ADON stated that equipment issues should be addressed immediately once staff has knowledge of it to prevent injury. In an interview on 12/10/25 at 03:39 PM with the ADM, he stated the falling star program is a way for them to be able to identify residents who are at risk for consistent falls; they put a star on the door to alert staff and make them more aware of interventions needed. He stated it was his expectation that when staff see that when doing room checks or working with residents that it brings extra awareness to fall checks and surroundings. The ADM stated Resident #1 tries to be independent, and staff try to be mindful of that. He stated Resident #1 was known for doing things on his own before staff assistance arrived to him. He was known for pushing the button, but still doing self-transfers. The ADM stated his expectation was when a wheelchair is provided, it was checked by the therapy department to ensure it is safe and functional. He stated if there were any issues, PT or maintenance would be the one to resolve the equipment issues. The ADM stated that every month there should be checks on the equipment to ensure it is in working order. He stated a negative outcome to Resident #1's wheelchair brakes not being functional would be the potential for him to slip out of the chair, or he could be doing something like self-transferring which could result in a fall if the wheelchair were to move from the brakes not working. The ADM stated he was not sure what the standard or facility policy was for how often a wheelchair assessment would be documented. Review of the facility's Fall Management System along with the Fall Prevention Program revised 12/2023 reflected: It is the policy of this facility to provide an environment that remains free of accident hazards as possible, It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Falling star:Identify high risk residents for falls. - Therapy will evaluate wheelchair for appropriateness; wheelchair size; functioning correctly. Event ID: Facility ID: 676095 If continuation sheet Page 3 of 3