Health inspection·April 28, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each resident had the right to access personal and medical records pertaining to himself or herself within 24 hours and allow the resident to obtain a copy of the records or any portions thereof upon request for 1 (Resident #1) of 6 residents reviewed for resident rights. The facility failed to provide a copy of Resident #1's medical records to Resident #1's RP after requesting the records on 02/21/25. This failure could place residents at risk of not having access to records when requested. Findings include: Review of Resident #1's Face Sheet, dated 04/28/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 01/13/25. Resident #1 was her own financial RP and care conference person and had someone designated as a financial RP and care conference person. Review of Resident #1's admission Record, dated 04/28/25, reflected she had diagnoses including unspecified dementia and cognitive communication deficit. Review of Resident #1's Quarterly MDS Assessment, dated 10/25/24, reflected she had a BIMS score of 1, which indicated she had severe cognitive impairment. Review of Resident #1's Care Plan, revised 10/28/24, reflected she was at risk for impaired cognitive function. Review of HIM's Email Thread, reviewed on 04/28/25, reflected the HIM emailed and asked Resident #1's RP to fill out and return the Authorization for Release of Information document on 02/25/25. Resident #1's RP emailed a completed Authorization for Release of Information document to the HIM, SW, ADM, and DON on 03/03/25. HIM emailed Resident #1's RP's completed Authorization for Release of Information document to the facility's legal team, ADM, and DON on 03/04/25. The facility's legal team emailed and informed the ADM and DON to release of Resident #1's medical records to Resident #1's RP on 03/05/25. During an interview on 04/28/25 at 9:08 p.m., the HIM stated she was responsible for receiving and processing residents' or RP's medical records requests. The HIM stated it took her three days to (continued on next page) 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 2 Event ID: 676238 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 676238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - North 11020 Dessau Rd Austin, TX 78754 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)