Health inspection·November 24, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility delayed Resident #1's catheter care for approximately 2.50 hours on 09/02/25 resulting in Resident #1 having discomfort and pain. This failure could place residents at risk of discomfort and pain, a decrease in their quality of life, quality of care, and dignity.Findings included:Record review of Resident #1's face sheet, dated 09/13/25, revealed a forty-one-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included paraplegia (damage to the spinal cord, the bundle of nerves that connects the brain to the lower body), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and ankylosing spondylitis of multiple sites in spine (an inflammatory disease that, over time, can cause some of the bones in the spine, called vertebrae, to fuse).Record review of Resident #1's care plan revealed a focus dated 01/03/25 of self-catheter (a way for you to empty your own bladder) and intervention dated 01/03/25 monitor and document intake and output. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 04/09/25 revealed a score of 15, indicating he was cognitively intact.Review of Resident #1's orders reflected in and out catheter (flexible tube called a catheter was inserted to drain fluids from the body) every 6 hours four times a day start date 01/05/2025 4:00 am, 10:00 am, 4:00 pm, and 10:00 pm. Review of Resident #1's MAR dated 09/02/25 for in and out catheter every 6 hours four times a day reflected Resident #1 received catheter care at 4:00 am with a urine output of 1100 ml, 10:00 am with a urine output of 900 ml, no entry for 4:00 pm, and 10:00 pm with urine output of 1500 ml.Interview on 09/13/25 at 12:06 pm with the ED reflected Resident #1 had an in and out catheter but Resident #1 did not like to do his own catheter care. The facility did it for them. The facility staff were trying to get him as independent as possible. Interview on 09/13/25 at 11:00 am with Resident #1 reflected the facility did not provide catheter care on 09/02/25 for about 2.5 hours after it was scheduled and he was in massive pain. He said it hurt until 4:00 am and they had to give him a pain pill. He said he heard someone in the hallway tell the ADON that he needed to have his catheter care, but the ADON said she would get to it when she had a chance. He said he asked two times to have his catheter emptied but no one came until about 2 hours later. He said he hurt so bad he had to ask for a pain pill. He said he felt that because they did not provide the catheter care on 09/02/25, it caused him to have a urinary tract infection. Interview on 09/13/25 at 3:41 pm with the NP reflected the facility told her that Resident #1 did not receive catheter care until approximately 6:00 pm on 09/02/25. Resident #1 refused to do catheter care on his own. Resident #1 told her on 09/02/25 he did not receive catheter care until approximately 2 Residents Affected - Few Page 1 of 6 676487 676487 11/24/2025 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hours later than he was supposed to have received catheter care and this caused a urinary tract infection. She said when he was tested a day or so after 09/02/25 (date of test unknown) he was positive for a urinary tract infection. The NP said the positive urinary tract infection cannot be directly related to the not being tapped (bladder stimulation by tapping to help empty the bladder) on 09/02/25 approximately 2 hours after it was scheduled. She was not sure when he was last catheterized prior to the approximately 6:00 pm catheterization. She said a bladder can retain urine and enlarge but when they were able to catheterize him approximately 2 hours later than he was usually catheterized, there was not a great deal of urine in his bladder. She said a full bladder was 600 ml to 650 ml and up and that was way too much for one bladder. She could not recall how much urine was in Resident #1's bladder when they catheterized him at approximately 6:00 pm. She said Resident #1 told him the story of the late cauterization the next day, 09/03/25, but he did not seem to be too upset about it and Resident #1 told her everything had improved, and everything was better. She said Resident #1 did not complain to her he was having symptoms of pain or discomfort. She said she had no concerns about his care at the facility. She said Resident #1 was afraid to do the in and out catheter self-care. She said he was not harmed at all by the situation of him getting catheterized approximately 2 hours late on 09/02/25 and she was not concerned at all about the nursing care treatment Resident #1 received at the facility. Interview on 09/13/25 at 5:35 pm with LVN A reflected Resident #1 had an in and out catheter and nursing staff had to assist him with his catheter. He said Resident #1 was care planned for a self-catheter, but the nurses had to make sure the catheter tubing went in the proper place. He said a nurse had to be there to guide the catheter tubing.Interview on 10/02/2025 at 2:29 pm with the ADON reflected she was told on 09/02/25 that Resident #1 asked for his catheter care to be done but she was in another resident's room because that resident had pain. She said it took about 40 minutes to handle the pain situation for that resident and then she was told by a family member of another resident that their family member was in pain. The ADON said that Resident #1 did not get his catheter taken care of until about 6:30 pm. The ADON said she never saw Resident #1 on 09/02/25 because another nurse took care of Resident #1's catheter care. She said no staff member told her Resident #1 was in pain and that he wanted her to go to him and do his in and out catheter care. She said it would have taken less than 5 minutes to do his in and out catheter care. The ADON was not aware of another nurse who could have helped Resident #1 with his in-and-out catheter care. She said maybe the facility placed other residents' needs before his, but there were 2 other residents who were in pain that had to be handled. Interview on 10/02/2025 at 4:16 pm with CNA B reflected Resident #1 did not complain of any pain when she assisted him to lay down at bedtime at approximately 10:00 pm on 09/02/25. CNA B said Resident #1 did not say he was miserable, and he needed someone to help him because he was uncomfortable. Interview on 10/02/25 at 4:24 pm with LPN A reflected she assisted Resident #1 with his catheter care at approximately 6:30 because he asked her to do it. She said the ADON never informed her Resident #1's catheter care was not done and Resident #1 said he had discomfort, so she catheterized Resident #1. She said Resident #1 was unable to straight catheterize himself. She said Resident #1 complained about having pain and Resident #1 said he felt better after he was catheterized. LPN A said Resident #1 normally did not complain and for him to say he was in pain, she knew something was wrong. She said Resident #1 said he hurt because he had not received catheter care. She said the ADON did not tell LPN A in the nurse's report when LPN A came on for duty that Resident #1 had not received his catheter care. Interview on 10/02/25 at 5:17 pm with the ED reflected LPN A did not document that she provided the catheter care to Resident #1 at approximately 6:30 pm instead of the 10:00 pm reflected in Resident #1 09/02/25 MAR. The ED said that Resident #1 676487 Page 2 of 6 676487 11/24/2025 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few probably felt his stomach was very full and he felt a little better after the catheter care was provided at approximately 6:00 pm on 09/02/25. The ED said depending on the situation he would have expected his staff to have done Resident #1's catheter care on 09/02/25 but if a resident was coding that resident would be the priority. He said two other residents were in pain and the ADON addressed their pain and the staff was addressing the most emergent situation, residents who were in pain. The Administrator said Resident #1 confirmed he received catheter care at 6:30 pm but LPN A did not document the catheter care as a late entry for approximately 6:00 pm but documented that the catheter care was provided at 10:00 pm. Interview on 10/02/25 at 6:20 pm with the DON, who did not work at the facility until after 09/02/25, reflected she did not think that Resident #1 would have been uncomfortable if he received catheter care approximately 2.50 hours late. She said that 1500 ml was an average amount of urine output. She said if he said he was uncomfortable, it could describe a large range of what was uncomfortable. She said that if there was an order to follow, staff needed to follow the order. She said she could not give an answer to the possible negative side effects of not giving him catheter care when it was ordered because there were too many possibilities. She said she visited Resident #1 when she began working at the facility and asked him if there was anything she could do for him and she asked about the staff and if he had any concerns. She said Resident #1 stated everyone had been great and he had no issues and no problems.Interview on 10/02/25 at 6:40 pm with the RN E reflected she had done a lot of resident catheter care and if there was an order for the in and out catheter, staff had an hour before and hour after the order to provide the care but there were circumstances when it did not happen at those times. She said that if a resident received catheter care approximately 2.5 hours later than the catheter time was ordered the resident could become uncomfortable and verbalize that he was uncomfortable. 1500 ml of urine output might be a lot, but it would depend on the medication the residents had been taking and what the resident had been drinking. The possible negative effects of catheterizing the resident after a scheduled order were the resident could be uncomfortable and might experience pain or distention (enlargement or swelling of a hollow organ or structure due to increased pressure or fluid accumulation within it). The resident could be upset or angry. It was the ultimate responsibility of the nurse taking the hall that day to make sure that this was taken care of. It was the responsibility of the nurse who was in charge of the resident to delegate the task. Interview on 10/02/25 at 6:56 pm with RN C reflected she did a lot of resident catheter care. She said if a resident did not receive catheter care according to the order it could be a problem, and multiple things could happen with the resident. She said the resident might be in pain and might be frustrated. She said orders should be followed and if you cannot follow the orders a nurse needed to get someone to assist or someone to follow up. She said it was the responsibility of the resident's nurse to have made sure catheter care was done. She said 1500 ml was a lot of urine output, but compared to Resident #1's average output, it looked normal. Review of facility policy for Dignity dated 04/02/2024 reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance. 676487 Page 3 of 6 676487 11/24/2025 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the medical record on each resident was complete and accurately documented for one (Resident #1) of five residents reviewed for accurate medical records. The facility documented in Resident #1's MAR that he received catheter care at 10:00 pm on 09/02/25 when Resident #1 stated he received catheter at approximately 6:30 pm on 09/02/25.This failure could place residents at risk of misdiagnosis, incorrect treatment, and poor quality of life.Findings included:Record review of Resident #1's face sheet, dated 09/13/25, revealed a forty-one-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included paraplegia (damage to the spinal cord, the bundle of nerves that connects the brain to the lower body), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and ankylosing spondylitis of multiple sites in spine (an inflammatory disease that, over time, can cause some of the bones in the spine, called vertebrae, to fuse).Record review of Resident #1's care plan revealed a focus dated 01/03/25 of self-catheter (a way for you to empty your own bladder) and intervention dated 01/03/25 monitor and document intake and output. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 04/09/25 revealed a score of 15, indicating he was cognitively intact.Review of Resident #1's orders reflected in and out catheter (flexible tube called a catheter was inserted to drain fluids from the body) every 6 hours four times a day start date 01/05/2025 4:00 am, 10:00 am, 4:00 pm, and 10:00 pm. Review of Resident #1's MAR dated 09/02/25 for in and out catheter every 6 hours four times a day reflected Resident #1 received catheter care at 4:00 am with a urine output of 1100 ml, 10:00 am with a urine output of 900 ml, no entry for 4:00 pm, and 10:00 pm with urine output of 1500 ml. Interview on 09/13/25 at 12:06 pm with the ED reflected Resident #1 had an in and out catheter but Resident #1 did not like to do his own catheter care. The facility did it for them. The facility staff were trying to get him as independent as possible. Interview on 09/13/25 at 11:00 am with Resident #1 reflected the facility did not provide catheter care on 09/02/25 for about 2.5 hours after it was scheduled and he was in massive pain. He said it hurt until 4:00 am and they had to give him a pain pill. He said he heard someone in the hallway tell the ADON that he needed to have his catheter care, but the ADON said would get to it when she had a chance. He said he asked two times to have his catheter emptied but no one came until about 2 hours later. He said he hurt so bad he had to ask for a pain pill. He said he felt that because they did not provide the catheter care on 09/02/25, it caused him to have a urinary tract infection. Interview on 09/13/25 at 3:41 pm with the NP reflected the facility told her that Resident #1 did not receive catheter care until approximately 6:00 pm on 09/02/25. Resident #1 refused to do catheter care on his own. Resident #1 told her on 09/02/25 he did not receive catheter care until approximately 2 hours later than he was supposed to have received catheter care and this caused a urinary tract infection. She said when he was tested a day or so after 09/02/25 (date of test unknown) he was positive for a urinary tract infection. The NP said the positive urinary tract infection cannot be directly related to the not being tapped (bladder stimulation by tapping to help empty the bladder) on 09/02/25 approximately 2 hours after it was scheduled. She was not sure when he was last catheterized prior to the approximately 6:00 pm catheterization. She said a bladder can retain urine and enlarge but when they were able to catheterize him approximately 2 hours later than he was usually catheterized, there was not a great deal of urine in his bladder. She said a full bladder was 600 ml to 650 ml and up and that was way 676487 Page 4 of 6 676487 11/24/2025 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few too much for one bladder. She could not recall how much urine was in Resident #1's bladder when they catheterized him at approximately 6:00 pm. She said Resident #1 told him the story of the late cauterization the next day, 09/03/25, but he did not seem to be too upset about it and Resident #1 told her everything had improved, and everything was better. She said Resident #1 did not complain to her he was having symptoms of pain or discomfort. She said she had no concerns about his care at the facility. She said Resident #1 was afraid to do the in and out catheter self-care. She said he was not harmed at all by the situation of him getting catheterized approximately 2 hours late on 09/02/25 and she was not concerned at all about the nursing care treatment Resident #1 received at the facility. Interview on 09/13/25 at 5:35 pm with LVN A reflected Resident #1 had an in and out catheter and nursing staff had to assist him with his catheter. He said Resident #1 was care planned for a self-catheter, but the nurses had to make sure the catheter tubing went in the proper place. He said a nurse had to be there to guide the catheter tubing.Interview on 10/02/2025 at 2:29 pm with the ADON reflected she was told on 09/02/25 that Resident #1 asked for his catheter care to be done but she was in another resident's room because that resident had pain. She said it took about 40 minutes to handle the pain situation for that resident and then she was told by a family member of another resident that their family member was in pain. The ADON said that Resident #1 did not get his catheter taken care of until about 6:30 pm. The ADON said she never saw Resident #1 on 09/02/25 because another nurse took care of Resident #1's catheter care. She said no staff member told her Resident #1 was in pain and that he wanted her to go to him and do his in and out catheter care. She said it would have taken less than 5 minutes to do his in and out catheter care. The ADON was not aware of another nurse who could have helped Resident #1 with his in-and-out catheter care. She said maybe the facility placed other residents' needs before his, but there were 2 other residents who were in pain that had to be handled. Interview on 10/02/2025 at 4:16 pm with CNA B reflected Resident #1 did not complain of any pain when she assisted him to lay down at bedtime at approximately 10:00 pm on 09/02/25. CNA B said Resident #1 did not say he was miserable, and he needed someone to help him because he was uncomfortable. Interview on 10/02/25 at 4:24 pm with LPN A reflected she assisted Resident #1 with his catheter care at approximately 6:30 because he asked her to do it. She said the ADON never informed her Resident #1's catheter care was not done and Resident #1 said he had discomfort, so she catheterized Resident #1. She said Resident #1 was unable to straight catheterize himself. She said Resident #1 complained about having pain and Resident #1 said he felt better after he was catheterized. LPN A said Resident #1 normally did not complain and for him to say he was in pain, she knew something was wrong. She said Resident #1 said he hurt because he had not received catheter care. She said the ADON did not tell LPN A in the nurse's report when LPN A came on for duty that Resident #1 had not received his catheter care. Interview on 10/02/25 at 5:17 pm with the ED reflected LPN A did not document that she provided the catheter care to Resident #1 at approximately 6:30 pm instead of the 10:00 pm reflected in Resident #1 09/02/25 MAR. The ED said that Resident #1 probably felt his stomach was very full and he felt a little better after the catheter care was provided at approximately 6:00 pm on 09/02/25. The ED said depending on the situation he would have expected his staff to have done Resident #1's catheter care on 09/02/25 but if a resident was coding that resident would be the priority. He said two other residents were in pain and the ADON addressed their pain and the staff was addressing the most emergent situation, residents who were in pain. The Administrator said Resident #1 confirmed he received catheter care at 6:30 pm but LPN A did not document the catheter care as a late entry for approximately 6:00 pm but documented that the catheter care was provided at 10:00 pm. Interview on 10/02/25 at 6:20 pm with the DON, who did not work at the facility until after 676487 Page 5 of 6 676487 11/24/2025 The Center at Parmer 13800 N Fm 620 Rd Sb Austin, TX 78717

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/02/25, reflected she did not think that Resident #1 would have been uncomfortable if he received catheter care approximately 2.50 hours late. She said that 1500 ml was an average amount of urine output. She said if he said he was uncomfortable, it could describe a large range of what was uncomfortable. She said that if there was an order to follow, staff needed to follow the order. She said she could not give an answer to the possible negative side effects of not giving him catheter care when it was ordered because there were too many possibilities. She said she visited Resident #1 when she began working at the facility and asked him if there was anything she could do for him and she asked about the staff and if he had any concerns. She said Resident #1 stated everyone had been great and he had no issues and no problems.Interview on 10/02/25 at 6:40 pm with the RN E reflected she had done a lot of resident catheter care and if there was an order for the in and out catheter, staff have an hour before and hour after the order to provide the care but there were circumstances when it did not happen at those times. She said that if a resident received catheter care approximately 2.5 hours later than the catheter time was ordered the resident could become uncomfortable and verbalize that he was uncomfortable. 1500 ml of urine output might be a lot, but it would depend on the medication the residents had been taking and what the resident had been drinking. The possible negative effects of catheterizing the resident after a scheduled order were the resident could be uncomfortable and might experience pain or distention(enlargement or swelling of a hollow organ or structure due to increased pressure or fluid accumulation within it). The resident could be upset or angry. It was the ultimate responsibility of the nurse taking the hall that day to make sure that this was taken care of. It was the responsibility of the nurse who was in charge of the resident to delegate the task. Interview on 10/02/25 at 6:56 pm with RN C reflected she did a lot of resident catheter care. She said if a resident did not receive catheter care according to the order it could be a problem, and multiple things could happen with the resident. She said the resident might be in pain and might be frustrated. She said orders should be followed and if you cannot follow the orders a nurse needed to get someone to assist or someone to follow up. She said it was the responsibility of the resident's nurse to have made sure catheter care was done. She said 1500 ml was a lot of urine output, but compared to Resident #1's average output, it looked normal. Review of facility policy for Dignity dated 04/02/2024 reflected Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance. 676487 Page 6 of 6