Health inspection·June 16, 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 interview and record review, the facility failed to provide specialized habilitation services and failed to obtain specialized durable medical equipment for one (Resident #1) of three residents reviewed for PASRR (Preadmission Screening Resident Review) services. The facility failed to request a customized mattress within 20 business days after the IDT meeting for Resident #1. This failure could put resident at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified convulsion (involuntary muscle contraction caused by abnormal brain activity. They can be symptom of epilepsy, fever, infection, injury or medication), Developmental Disorder of scholastic skills (group of conditions that hinder the acquisition of fundamental academic abilities), cognitive communication deficit (difficulties in communication that stem from disruptions in cognition process such as attention, memory, reasoning and executive function), unspecified intellectual disabilities, Review of Resident #1's quarterly MDS assessment, dated 04/15/25, reflected a BIMS score of 10, indicating he had moderate cognitive impairment. Review of Resident #1's quarterly care plan, initiated 3/04/2025 reflected he had been identified as having PASRR positive status related to an intellectual disability (ID) with interventions Specialized services CMWC/DME will be provided as determined by IDT meeting, therapy services as ordered. Review of Resident #1's IDT Care Conference, dated 01/21/25, reflected the following summary: PASRR Care Plan Meeting, Special Treatments, Procedures and Devices-WC, On PT, OT Goal is to keep strengthening and walking. Review of Resident #1's IDT Care Conference, dated 05/1/25, reflected the following summary: On PT, OT, ST PT: Working on balance, gait, strengthening OT: Working on ADLs and fine motor skills ST: Page 1 of 3 676459 676459 06/16/2025 Sedona Trace Health and Wellness Center 8324 Cameron Rd. Austin, TX 78754

F 0644 Resident #1's IDT meetings did not address the use of supportive mattress. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 06/16/2025 at about 11:00 am the Resource Nurse / MDS Nurse stated Resident #1 was positive for PASRR due to ID and was being skilled by PT/OT/ ST. The Resource Nurse also stated Resident #1 was being skilled upon admission therefore his PASRR services were not approved until his Medicaid was approved. She stated Resident #1's services were based on the initial IDT meeting held on 4/15/2025 after his PASRR approval. The Resource Nurse stated specialized services should be provided to the Resident by the 20th day after IDT meeting. Residents Affected - Few During an interview on 06/16/2025 at about 11:27 am, the DOR stated Resident #1's PASRR meeting was held on 1/21/2025 while he was still being skilled. The DOR stated the IDT team discussed customized wheelchair and mattress (pressure relieving). The DOR stated Resident #1 was skilled from 12/04/2025 through 2/3/2025. She stated she submitted a referral for PASRR services on 2/4/2025 and she kept getting push backs for so many reasons. The DOR stated Resident #1's customized wheelchair was delivered on 5/15/2025, the mattress would have been delivered earlier but was not ordered duet to safety reasons (there was another resident on the same mattress who kept falling off). The DOR stated she did not document in Resident #1's records why the mattress was not ordered. The DOR stated PASRR forms should be submitted by day 20. The DOR stated she communicated to the PASRR representative why she did not order the mattress but did not note it in Resident #1's Portal profile. During a telephone interview on 06/16/2025 at 12:23 pm, the PASRR Program Specialist stated when a resident was admitted and was PASRR positive, an IDT meeting was held, and services were recommended. The facility then had 20 business days to send the NFSS out for approvals. She stated Resident #1's facility did not send the form within 20 business days. She stated that was when she sent out a courtesy email encouraging compliance. She stated if she received no response from that, she then made a complaint to HHSC. She stated if the facility did not document within the timeframe, regardless of what the issue was the facility was not in compliance. She stated the facility was responsible to document in the long-term portal the services recommended and if those services were provided for the resident within the timeframe. During an interview on 06/16/25 at 12:34 pm, the Administrator stated she after the PASRR IDT meeting, it was the expectation that the facility communicates with PASRR and provide the services as was discussed in the IDT meeting. During another interview on 6/16/2025 at about 1:28 pm, the DOR stated during the 1/21/2025 meeting, the team discussed about the mattress, but she could not see it documented on the facility's side. The DOR stated she could only see the discussion of the wheelchair. The DOR stated Resident #1's Habilitation Coordinator asked if she wanted Resident #1 to have a specialized WC and mattress and she accepted. She stated Resident #1 needed the wheelchair and the team along with Resident #1 and his family wanted him to try the mattress. Review of the facility titled PASRR POLICY AND PROCEDURE undated reflected: The facility will designate an individual to follow up on ALL residents have received a PASRR Level I screening. If Facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation. C. 676459 Page 2 of 3 676459 06/16/2025 Sedona Trace Health and Wellness Center 8324 Cameron Rd. Austin, TX 78754

F 0644 Level of Harm - Minimal harm or potential for actual harm Coordinate with the local authority to ensure that the individual is properly assessed for any specialized services recommended in the Level II evaluation as being needed when a determination of ID, DD, or MI is made. (Under 40 TAC Chapter 19, the NF is responsible for assessing the individual for PT, OT, and ST needs and for Durable Medical Equipment. Residents Affected - Few If specialized services are assigned, the NF MUST: A. Certify that they can provide, arrange for, or support services recommended in the Level II evaluation. B. Document the roles and responsibility of the NF in carrying out that specialized service in the Comprehensive care plan. C. Provide training to NF staff on their roles and responsibilities in ensuring that the specialized service is provided. D. Document in the individual's clinical record that the specialized service is provided consistent with the care plan. 676459 Page 3 of 3