Health inspection·November 19, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6(Resident #1) residents reviewed for PASARR. The facility failed to ensure that Resident #1 was referred for a level II PASARR after an evident diagnosis of Major Depressive Disorder diagnosed on [DATE]. These failures could place residents at risk for decline and the inability to receive services. Findings Included:RR of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. The face sheet revealed that Resident #1 had a diagnosis of Major Depressive Disorder as of 10/06/2025. RR of Resident #1's MDS record dated 10/02/2025 revealed that Resident #1 had a psychological diagnosis of depression. RR of Resident #1's undated care plan revealed that Resident #1's diagnosis included major depressive disorder. The care plan did not indicate if Resident #1 received PASARR services. RR of Resident #1's Level 1 PASARR screening dated 09/27/2025 revealed a negative MD, ID and/or DD diagnosis. An interview on 11/19/2025 at 3:24 PM, the MDSC who had been employed at the facility since 2021,. stated that he had received training on abuse and neglect. The MDSC stated that he was in charge of PASARR screenings. The MDSC stated a Level 1 PASARR screening should be done upon admission and after a change of condition or new diagnosis. The MDSC stated that a diagnosis that could indicate a positive MD, ID, or DD would be Schizophrenia, bipolar disorder, major depressive disorder and epilepsy. The MDSC stated it could negatively affect a resident if their level 1 screening was inaccurate by the inability to receive services appropriate for their needs. The MDSC stated when a resident had a positive Level 1 and Level 2 PASARR, the facility should immediately alert the local authority to conduct an IDT meeting. An interview on 11/19/2025 at 3:43 PM, the DON who had been employed at the facility since October 2024,. stated she had received training on abuse and neglect. The DON stated that neglect could be identified as not providing care timely. The DON stated that a new diagnosis of MD, ID or DD would initiate a new PASARR screening. The DON stated the function of PASARR would be to provide services for residents. The DON stated if the PASARR screening was incorrect, it could affect the resident by not receiving the services necessary. The DON stated the MDSC is responsible for PASARR issues. An interview on 11/19/2025 at 4:02 PM, the ADM who had been employed at the facility since March 2025, stated she had received training for abuse and neglect. The ADM stated neglect could be recognized as the failure to provide services to residents. The ADM stated the policy on PASARR was to conduct a screening upon admission and at change of condition/diagnosis. The ADM stated that the MDSC conducts the PASARR screenings. The ADM stated that a diagnosis of MI would trigger a positive PASARR level 1 assessment. The ADM stated that if resident's level 1 PASARR was incorrect it could negatively affect a resident by not having access to services that they need that are provided though the state. RR of list of PASARR Page 1 of 4 455771 455771 11/19/2025 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0644 positive residents dated 11/19/2025 revealed, Resident #1 was not listed on the form. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455771 Page 2 of 4 455771 11/19/2025 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for 1 of 6 (Resident #2) residents reviewed for PASARR. The facility failed to ensure that Resident #2 was referred to PASARR services after a positive level II PASARR screening. These failures could place residents at risk for not receiving services intended for the residents mental, intellectual or developmental disabilityFindings Included: RR of Resident #2's undated face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE]. The face sheet revealed that Resident #2 had a diagnosis of Major Depressive Disorder as of 03/14/2013. RR of Resident #2's MDS record dated 09/01/2025 revealed that Resident #2 had a psychological diagnosis of depression. Resident #2 had a BIMS of 14, which indicate moderate impaired cognitive function. RR of Resident #2's undated care plan revealed that Resident #2 had a diagnosis of Major Depressive Disorder, mild. The care plan did not indicate if Resident #2 received PASARR services. RR of Resident #2's PASARR screening dated 06/19/2025 revealed the Recommended Nursing Facility Specialized Services for the following areas:1. Physical Therapy2. Occupational Therapy3. Speech Therapy RR of Resident #2's PASARR services letter dated 10/17/2024 revealed that Resident #2 was approved for Physical Therapy services. RR of Resident #2's PASARR services letter dated 10/18/2024 revealed that Resident #2 was approved for Occupational Therapy services. RR of a list of PASARR positive residents dated 11/19/2025 revealed, Resident #2 had been PASARR positive since 07/01/2021. An interview was conducted on 11/19/2025 at 11:12AM with the complainant who reported the facility neither initiated the PASARR Specialized services late (which should be done within 20 business days) and/or not at all for Resident #2. An interview on 11/19/2025 at 3:24 PM, the MDSC who had been employed at the facility since 2021. MDSC stated that he was in charge of PASARR screenings. The MDSC stated if a resident had received a positive PASARR 1 and positive PE, the facility should have submitted a referral within 90 days of the last IDT meeting. MDSC stated it could negatively affect a resident if their level 1 & 2 PASRR screenings were positive, but a referral had not been done because of discrepancy which would cause the resident to not have access to the services. An interview on 11/19/2025 at 3:43 PM, the DON who had been employed at the facility since October 2024,. stated she had received training on abuse and neglect. The DON stated that a new diagnosis of MD, ID or DD would initiate a new PASARR screening. The DON stated the function of PASARR would be to provide services for residents. The DON stated if the PASARR screening was incorrect, it could affect the resident by not receiving the services necessary. An interview was conducted on 11/19/2025 at 4:02 PM, the ADM who had been employed at the facility since March 2025The ADM stated that a resident who had a positive Level 1 and Level 2 PASARR screen qualify for more services. The ADM stated the facility would then send the referral for PASARR services. The ADM stated the timeline to complete the referral after the IDT meeting would be 20 days. The ADM stated it could negatively affect a resident if their level 1 & 2 screenings were positive, but a referral had not been done because a resident would not receive the services that are rendered for them. The ADM stated they had forgotten to send the referral over during the allotted timeframe of 20 days for Resident #2. RR of a facility provided document titled Pre-admission Screening & Resident Review dated 05/10/2021 which revealed the following:1. The PASARR Level 1 Screen, the MDS coordinator in the event of a positive PL1 will notify the LIDDA within 2 calendar days of admission to schedule the IDT and initiate the PE process.Will review the PE print the form and place in the medical 455771 Page 3 of 4 455771 11/19/2025 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0646 record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455771 Page 4 of 4