Health inspection·May 11, 2023

F 0577 Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete said she believed the facility's corporate office representatives were reviewing the binder as part of their mock survey process and did not return the binder to the table. The ADM later said she found the binder in her office on one of her shelves. The ADM said she was responsible for ensuring the results were posted in a place readily accessible. A Federal Residents Rights policy and procedure revised on 2/24/22 stated under the Information and Communication Section, You have the right to: ? examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. Event ID: Facility ID: 676459 If continuation sheet Page 2 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, for 1 of 4 residents (Resident #84) reviewed for a homelike environment. The facility failed to ensure the dents and scuffs on the interior wall of Resident #84's room were repaired and painted. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Review of Resident #84's face sheet on 05/10/23 reflected the resident was an [AGE] year-old male and was admitted to the facility on [DATE]. The diagnoses included Encephalopathy (damage or disease that affects the brain), Heart failure, Retention of Urine, Hyperlipidemia (too much fat in the blood), Hypertension (High Blood Pressure), Cerebral Infarction (stroke), Muscle Wasting, Lack of Coordination, Unsteadiness on feet and Low back Pain. Record review of the MDS assessment dated [DATE] revealed Resident #84 had a BIMS of 14 which indicated intact cognition and only required supervision for bed mobility, transfers, and eating. During an observation on 05/10/23 at 10:00 AM, it was revealed there were two parallel vertical dents on one of the walls with 4-inch (approx.) space in between them. Each dent was measuring approximately 24-inch L x 3inch W x 1.5-inch or less D (max. at the middle of the dent). There were also scuff marks of various sizes and shapes at various places of the walls. During an interview on 05/10/23 at 10:00 AM, Resident #84 said his only concern about living at the facility was his ugly looking room due to the dents and scuff marks on the wall. Resident #84 stated he had reported the problem multiple times to different staff members since he was admitted to the facility on [DATE]. Resident #84 stated he was very disappointed that no one came into his room to address the issue. Resident #84 stated he saw maintenance people fixing things in his hall (Hall 100) on many occasions. However, nobody cares to come and repair the damages on the wall in his room. During an interview on 05/10/23 at 11:30 AM, AS stated she was the Guardian Angel (Care Coordinator) for Resident #84. AS stated, she started her job as AS on 04/10/23. She said Resident #84 complained to her about the damaged wall sometime in the 2nd week of April 2023. AS stated, as the condition of the wall needed repair work, she immediately filled out the facility 'Guardian Angel Complaint Sheet stating about the damaged wall and handed over to ADM. When investigator asked about the follow up on the complaint AS stated she did not do any follow up on it. During an interview on 05/11/23 at 11:00 AM., MAINT stated he started working at the facility about three months ago. MAINT stated he was unaware of the damage on the wall as it was not communicated to him by anyone. MAINT said he created a maintenance log based on reports from various sources (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 3 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm including reports from staff. MAINT said he interview residents individually as well to know their requirements and had not yet interviewed Resident #84. The investigator requested a copy of the log however, MAINT was unable to produce it. He stated the log was saved on his mobile phone and did not know how to make a copy. MAINT stated he had some maintenance works two weeks ago in Hall 100. However, he did not go to Resident #84's room since he was unaware of the issue. Residents Affected - Few During an interview on 05/11/23 at 3:00 PM, DON stated it was the responsibility of the staff to make the facility a homelike environment. She stated this was achieved by allowing residents to have their personal belongings as much as possible and providing clean, neat, and tidy environment at the facility all the time including individual rooms of the residents. DON stated the damage on Resident #84's wall had to be serviced as soon as resident reported about it. When the investigator asked about the reporting, DON stated any staff who noticed the issue should have reported it to MAINT. During an interview on 05/11/23 at 3:30 PM., ADM said she received the Guardian Angel Report from AS about the damaged wall in Resident #84's room. ADM said she did communicate about it with MAINT as the repair work in Resident #84 was important to create a comfortable environment for the resident at the facility. When investigator asked about the follow up on the repair, ADM stated she did not do any follow up to make sure the work was completed and reported that MAINT was already started working on it Review on 05/11/23 of facility policy Resident Rights and Responsibilities revised in 01/2022 reflected: It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility . . Safe Environment: You have a right to a clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 4 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide food that accommodates resident's preferences for one (Resident #62) of four residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to provide Resident #62 with her food preferences with consistency, for breakfast and lunch during her entire stay at the facility from the day of admission [DATE]). Resident #64 requested not to have tomatoes, sausage, and eggs. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for adverse effect from food, frustration, not enjoying meals, and weight loss. Findings included: Review of Resident #62's face sheet on 05/10/23 reflected the resident was a [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Displaced subtrochanteric fracture of right femur (fracture of the top of the thigh bone), Dementia, Psychotic Disturbance, Anxiety, Type 2 Diabetes Mellitus, Hyperlipidemia (Excessive fat in blood), Chronic Kidney Disease, Cognitive Communication Deficit, Dysphagia (Difficulty in swallowing), Muscle Weakness, Repeated Falls, Heart Disease, Hypertension, Vitamin D Deficiency and Chronic Kidney Disease. Record review of the MDS assessment dated [DATE] revealed Resident #62 had a BIMS of 15 which indicated intact cognition and required supervision for transfers, personal hygiene, and eating. Record review on 05/11/23 of Resident #62's care plan dated 11/15/22 revealed that there was no care plan for Resident #62's food preferences. Record review on 05/11/23 of the progress note for Resident #62 by RD dated 11/30/22 and 02/02/23 stated: . Would like no sausage, no eggs, no coffee, no pancakes, no tomatoes, no orange juice. Would like oatmeal and milk at breakfast. During an interview on 05/09/23 at 12:45 PM with Resident #62, she stated she had complained multiple times to the facility about non consideration of her food preferences. Resident #62 stated that issue persisted since her day of admission at the facility (11/08/22). Resident #62 stated her report to the nursing staff and the dietician at various occasions did not yield any positive outcome. Resident #62 stated, at that time, she used her refrigerator in her room to store the food of her choice as some days, the facility served food that she did not want. Resident #62 stated she had a history of stomach ulcer and tried to avoid anything acidic and the kind of food that generate too much gastric acid. She stated she was frustrated due to the inaction from the facility and started storing her choices of food in the refrigerator as an alternative solution. Interview on 05/11/23 at 11:00 AM with the MDSN revealed she was the Guardian Angel (Care Coordinator) of Resident #62. She stated on 05/11/23, the facility served sausage and eggs and later this was substituted with oatmeal and milk on resident's request. MDSN stated she was under the impression (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 5 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0806 that all these days, the kitchen was serving the food the resident had requested. Level of Harm - Minimal harm or potential for actual harm Interview on 05/11/23 at 1:00 PM with the DS revealed, on 5/11/23 Resident #64 was served with sausage and egg for breakfast and on 5/10/23, BBQ pork Riblet with BBQ sauce on top of it, [NAME] Slaw, and Pinto beans for lunch. DS said on both days Resident #62 declined the food served. When investigator asked about Resident #62's food preferences, DS stated she was unaware of any restrictions on food. She said she understood residents' food choices through the instructions by RD and personal interviews. DS stated she started working at the facility about two months ago and yet not interviewed Resident #62. RD said she never received any instructions from DS about Resident #62's food preferences. Residents Affected - Few During the interview over the telephone on 05/11/23 at 2:00 PM with family member of Resident #62 it was revealed Resident #62 did not eat eggs, sausage, and anything too acidic like tomatoes. He stated Resident #62 had history of stomach ulcer and was on food restrictions. He said the food restrictions were already there somewhere on Resident #62's medical records. He said Resident #62 was somewhat shy to express her needs assertively and had the nature of looking for alternative solutions instead. During the interview on 05/11/23 at 2:30 pm, the SRD revealed she was the supervisor of RD and RD was no longer working with the facility. SRD said she was aware of RD's lack of communication in general with DS and other staff members about residents' food choices, preferences, and restrictions. SRD stated it must have been frustrating for Resident #62 as her preferences were not addressed properly for a very long period. SRD stated this aspect of the care was taken care of already and the new RD for the facility would not repeat the same mistake. During the interview on 05/11/23 at 3:00 PM, the DON stated it was the responsibility of the facility to respect Resident #62's food preferences. She stated it was frustrating for the resident when her needs were not met in a timely manner. When investigator asked about care planning, the DON stated Resident #62's food preferences should have been in the care plan. She stated the lack of a care plan was one of the reasons for that issue. During an interview on 05/11/23 at 3:30 PM, the ADM stated she expected the staff at the facility to honor resident food preferences. When investigator asked about the potential negative outcome, ADM stated it would affect residents' health and quality of life, Dignity, and a possibility of weight loss. Record review on 05/11/23 of Facility policy Food and nutrition Services revised in 09/2017 reflected: It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices including their nutritional, religious, cultural, ethnic and including liberalizing diet needs while using established national guidelines. 1. Menus prepared will reflect facility's reasonable efforts to include religious, cultural, and ethnic needs of the resident population with input received from residents and resident groups. Record review on 05/11/23 of Facility policy Leadership, Nursing Services revised in 05/2007 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 6 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0806 reflected: Level of Harm - Minimal harm or potential for actual harm . Nursing service staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhance each resident's dignity and respect in full recognition of his or her individuality . Residents Affected - Few . Resides and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered . . Chooses activities schedules and health care consistent with his or her interest, assessments, and plans of care and makes choices about aspects of his or her life in the facility that are significant to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 7 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 6 of 10 residents reviewed for the usage of Blood Pressure Monitors (Resident #28, Resident #73, Resident #41, Resident #75, Resident #84, and Resident #198) as indicated by: Residents Affected - Some The facility failed to ensure MA B, MA C and LVN A disinfected the blood pressure monitors between the residents. These failures could place the residents at risk for cross contamination and infection. Findings included: Review of Resident #28's face sheet on 05/10/23 reflected the resident was an [AGE] year-old female and was admitted to the facility on [DATE].The diagnoses included Heart failure, Hypertension (High Blood pressure) , History of Falling, Insomnia, Anemia, Major Depressive Disorder, Vitamin D Deficiency, Retention of Urine, Hyperlipidemia (Excess fat in blood), Seasonal Allergic Rhinitis(Common Allergy) , Type 2 Diabetes Mellitus, Muscle Weakness, Cognitive Communication Deficit, Dysphagia (Difficulty in swallowing), Dementia, Psychotic Disturbance, Mood Disturbance and Anxiety. Record review on 05/10/23 of Resident #28's MDS assessment dated [DATE] revealed a BIMS score of 07 out of 15 indicating the cognition of the resident was severely impaired. Record review on 05/10/23 of Resident #28's MAR of May,2023 reflected: Carvedilol Tablet 25 MG. Give 1 tablet by mouth two times a day for HTN hold for SBP <110, HR <60. Review of Resident #73's face sheet on 05/10/23 reflected the resident was a [AGE] year-old male and was admitted to the facility on [DATE]. The diagnoses included Muscle weakness, Cognitive Communication Deficit, Abnormalities of Gait and Mobility, Dysphagia (Difficulty in swallowing), Muscle Wasting and Atrophy (Decrease in muscle size), Pain, Dementia, Psychotic Disturbance, Mood Disturbance, Anemia, Type 2 Diabetes Mellitus, Hyperlipidemia (Excess fat in blood), Chronic Constipation, Depression, Chronic Obstructive Pulmonary Disease (Breathing Difficulties) and Age-Related Physical Debility. Record review on 05/10/23 of Resident #73's MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 indicating the cognition of the resident was moderately impaired. Record review on 05/10/23 of Resident #73's MAR of May,2023 reflected: Carvedilol Oral Tablet 3.125 MG (Carvedilol), Give 1 tablet by mouth two times a day for HTN hold for SYT <110 <60 During an observation on 05/10/23 at 10:00 AM revealed MA B was administering medications to the residents in Hall 200. MA B used a wrist blood pressure monitor to take blood pressure of Resident #28 and then administered the ordered medications. After that he moved on to Resident#73 and took blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 8 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pressure using the same blood pressure monitor. MA B did not sanitize the blood pressure monitor before and after using it on Resident#28 and after the completion on Resident#73. During an interview on 05/10/23 at 10:30 AM, MA B stated he forgot to sanitize the blood pressure monitor before and after he used it on residents. He said sanitizing the monitor was necessary to minimize the spread of transmittable diseases. When the investigator asked about the training or in-services she received, MA B stated there were in-services on infection control every now and then. However, he did not remember if he received any in-service specific to sanitization of medical equipment. Review of Resident #41's face sheet on 05/10/23 reflected the resident was an [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Unsteadiness on feet, Anoxic Brain Damage (Brain damage due to lack of oxygen supply), Epilepsy(seizure disorder), Muscle Weakness, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Hypertension, Cognitive Communication Deficit, Dementia, Agitation, Anxiety Disorder, Insomnia and Major Depressive Disorder. Record review on 05/10/23 of Resident #41's MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 indicating the cognition of the resident was moderately impaired. Record review on 05/10/23 of Resident #41's MAR of May,2023 reflected: Lisinopril Tablet 5 MG. Give 1 tablet by mouth one time a day for HTN Hold if SBP<110, P<60 Review of Resident #75's face sheet on 05/10/23 reflected the resident was an [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Hypertensive Heart Disease, Acute Embolism and Thrombosis (Blood clot in blood vessel and moving this clot through the blood stream) , Pain in right leg, Unsteadiness on Feet, Other abnormalities of gait and mobility, Muscle Weakness, Dysphagia (Difficulty swallowing), Cognitive Communication Deficit, Dementia, Anxiety, Schizophrenia, Major Depressive Disorder and Dysuria (Painful Urination). Record review on 05/10/23 of Resident #75's MDS assessment dated [DATE] revealed a BIMS score of 99 out of 15 indicating the cognition of the resident could not determine. Record review on 05/10/23 of Resident #75's MAR of May,2023 reflected: Lisinopril Tablet 5 MG. Give 1 tablet by mouth one time a day for HTN Hold if SBP<110, P<60. During an observation on 05/10/23 at 11:00 AM revealed LVN A was administering medications to the residents in Hall 400. LVN A used a wrist blood pressure monitor to take the blood pressure of Resident #41 and then administered the ordered medications. After that she moved on to Resident #75 and took blood pressure using the same blood pressure monitor. LVN A did not sanitize the blood pressure cuff before and after using it on Resident #41 and after the completion on Resident #75. During an interview on 05/10/23 at 1:00PM, LVN A stated she was aware that sanitizing medical equipment before and after the use on residents was important to control the infections that were transmittable. LVN A said she was in a hurry and forgot to sanitize the blood pressure monitor. When the investigator asked about the training or in-services she received, LVN A stated she did not remember any in-service she received on sanitization of medical equipment in the past. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 9 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of Resident #84's face sheet on 05/10/23 reflected the resident was an [AGE] year-old male and was admitted to the facility on [DATE]. The diagnoses included Encephalopathy (disease of the brain that alters brain function), Heart failure, Retention of Urine, Hyperlipidemia (Excess fat in blood), Hypertension, Cerebral Infarction (stroke), Muscle Wasting, Lack of Coordination, Unsteadiness on feet and Lower back Pain. Residents Affected - Some Record review on 05/10/23 of Resident #84's MDS assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating the cognition of the resident was moderately impaired. Record review on 05/10/23 of Resident #75's MAR of May,2023 reflected: Cozaar Oral Tablet 25 MG (Losartan Potassium). Give 1 tablet by mouth two times a day for HTN hold if SBP<110 p<60. Amlodipine Besylate Oral Tablet, 10 MG (Amlodipine Besylate), Give 1 tablet by mouth one time a day for HTN hold if SBP <110 p 60. Hydrochlorothiazide Oral Tablet 25 MG (Hydrochlorothiazide), Give 1 tablet by mouth one time a day for HTN hold for SBP <110 p<60. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate), Give 1 tablet by mouth one time a day for HTN hold if SBP<110 p<60. Review of Resident #198's face sheet on 05/10/23 reflected the resident was a [AGE] year-old female and was admitted to the facility on [DATE]. The diagnoses included Hyperlipidemia (Excess fat in blood), Diabetes Mellitus, Constipation, Hypertension, Schizophrenia, Major Depressive Disorder, and Pain Record review on 05/10/23 of Resident #198's MDS assessment dated [DATE] revealed that Resident #198 was a newly admitted resident (on 05/03/23), and the BIMS was not completed. Record review on 05/10/23 of Resident #75's MAR of May,2023 reflected: Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate), Give 0.5 tablet by mouth two times a day for HTN Hold for SBP<110 or DBP<60. An observation on 05/10/23 at 11:30 AM revealed MA C was administering medications to the residents in Hall 100. MA C used a wrist blood pressure monitor to take the blood pressure of Resident #84 and then administered the prescribed medications for blood pressure as per the order. After that she moved on to Resident #198 and took the blood pressure using the same blood pressure monitor. MA C did not sanitize the wrist blood pressure monitor before and after using it on Resident#84 and after the completion on Resident #198. During an interview on 05/10/23 at 1:30PM, MA C stated she forgot to sanitize the pressure monitor before and after using it. She said sanitizing pressure monitor in between the residents was important to control infections. When the investigator asked about the training or in-services she received, MA C stated she received in-services on infection control every month. She said she did not receive any in-service on sanitization of medical equipment in the recent past. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 10 of 11 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 676459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sedona Trace Health and Wellness Center 8324 Cameron 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with DON on 05/11/23 at 3:00 PM, DON stated the staff followed the instructions in the facility policy. DON stated medical equipment should be sanitized before and after and in between the residents to minimize the spread of transmittable diseases. The staff who were non-compliant to the policy were identified by observation and then provide in-services. During an interview with ADM on 05/11/23 at 3:30PM, she stated staff was required to follow facility policy. When the investigator asked how the facility ensured an effective infection control at the facility, ADM said the facility achieved that through tracking, infection control auditing and clinical meetings. When ADM was requested to further elaborate, she explained staff were constantly observed and monitored by DON who was the Infection Preventionist to identify deficiencies in infection control. She stated the identified staff were trained and an in-service was conducted for all the staff members. Record review of the facility's in-services conducted at the facility as of 04/05/23, since 01/01/23, reflected there were no in-services on disinfection of medical Equipment. Record review on 05/11/23 of the facility's policy IPCP Standard and Transmission-Based Precautions revised in 10/22 reflected: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . . Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . . 2. Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. (e.g., MDROs) . . c. Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676459 If continuation sheet Page 11 of 11