Health inspection·July 21, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 16 resident (Resident #61) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #61 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record review of Resident #61's face sheet dated 07/21/2023, revealed an admission date of 06/21/2023, Record review of Resident #61's medical record revealed that as of 07/18/2023, no admission assessment MDS had been completed. Section A of the MDS assessment was still showing as incompleted. Interview with MDS Coordinator B on 07/21/23 at 11:40 a.m. revealed the time frame for an initial MDS to be completed was 14 days from admission. He stated he was not the only MDS nurse for the facility and had not done the assessment for Resident #61. He did no know why the other MDS had not completed the assessment on time. He revealed they used the RAI manual as reference and they had electronic access to the manual. He revealed an incomplete admission assessment was putting the resident at risk for improper care. Interview with the Administrator on 07/21/2023 at 11:45 a.m. revealed the Administrator was not aware the assessment was late. Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the endn of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676099 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 676099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbour at Westminster Manor 4200 Jackson Ave Austin, TX 78731 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)