Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sedona Trace Health And Wellness Center during CMS and state inspections, most recent first.
Failure to Notify Primary POA of Discharge: A resident with intact cognition, mobility limitations, and incontinence was discharged with a family member after the DON approved the discharge request from the alternate POA. The primary POA was not notified before or after the discharge, despite a POA document naming him as the primary agent and interviews showing he wanted the resident to remain in the facility until a safe plan was arranged. Staff documented the discharge and stated they relied on the family member present, while the SW and ADON noted family dynamics and that the primary POA was more involved in care decisions.
A resident with pneumonia, anemia, major depressive disorder, weakness, reduced mobility, and incontinence was discharged after staff relied on FM B’s request without verifying the home setting or clarifying family authority. The SW and DC did not confirm the discharge destination, and the DON believed FM B was the primary POA even though the POA document named FM A as primary. FM A said he was not consulted, wanted the resident to remain until a safe home health plan was arranged, and learned of the discharge only after it occurred.
Expired supplies were found in the 100/200-hall med room, including IV catheters, syringes, and needles past their expiration dates. MA A, the ADON, the DON, and the ADMIN each described daily checks for expired meds and supplies, but the items remained in stock despite the facility policy requiring outdated or contaminated items to be immediately removed.
A resident with intellectual disability and other complex needs did not receive a specialized mattress within the required timeframe after an IDT meeting, and the facility failed to document the delay or the rationale for not ordering the equipment. The need for the mattress was discussed but not recorded in the care plan or portal, and required PASRR documentation was not submitted on time, resulting in a deficiency.
A resident with severe cognitive impairment and mental health issues was not readmitted to the facility after being sent to a psychiatric hospital. The facility did not provide a 30-day discharge notice or adequately prepare for the discharge. The resident's escalating behaviors and the facility's inability to meet her needs led to the decision not to readmit her, contrary to the facility's policy.
Two residents' bathroom and shower call lights were non-functional for about a month, posing a risk to their safety. Despite attempts to repair, the issue persisted, and staff were unaware or inconsistent in addressing the problem. Maintenance acknowledged ongoing issues, and the facility's call light testing system failed to indicate the inoperability.
A facility failed to properly store oxygen equipment for three residents, risking cross-contamination. Despite staff training, nasal cannulas and tubing were left on surfaces instead of being bagged. The facility lacked a specific policy on storage, leading to this oversight.
The facility failed to maintain professional standards for food storage and sanitation. Kitchen staff did not properly secure their hair with hairnets, and the ice machine had black spots indicating poor maintenance. Expired food items were found in the walk-in refrigerator, and the walk-in freezer had ice buildup due to improper door closure. The Dietary Manager admitted to a lack of documentation and awareness of expired items, and the facility lacked policies on food storage and cleaning practices.
The facility failed to ensure the completion and validation of advanced directives for two residents, risking the non-honoring of their medical wishes. One resident's OOH-DNR form lacked a printed name and date, while another's MPOA was missing signatures and witness acknowledgment, rendering it invalid. Staff interviews confirmed these deficiencies.
The facility failed to include a cancer diagnosis for a resident and a depression diagnosis for another in their comprehensive assessments, despite both having relevant physician's orders. The MDS coordinator, DON, and ADM acknowledged the importance of accurate MDS assessments, as outlined in the RAI manual.
A facility failed to conduct a PASRR Level II evaluation for a resident with schizophrenia and bipolar disorder due to an incorrect PASRR Level I screening. Despite the resident's known mental health diagnoses, the screening was not corrected, and the necessary evaluation was not performed. Interviews with staff revealed a lapse in following the facility's process for identifying and addressing mental health needs.
Three residents in the facility were found with unclean and improperly maintained nails, despite their need for assistance with activities of daily living (ADLs). A resident with severe cognitive impairment had a blackish substance under her nails, while another resident with moderate cognitive impairment requested nail cleaning but did not receive it. A third resident with diabetes had uneven and dirty nails, contrary to his care plan. Staff interviews revealed that nail care was supposed to be part of the shower routine or done as needed, but this was not adequately provided.
Failure to Notify Primary POA of Resident Discharge
Penalty
Summary
The facility failed to ensure the resident’s primary POA, FM A, was notified when Resident #1 was discharged with FM B. Resident #1 was admitted with pneumonia, anemia, major depressive disorder, muscle weakness, reduced mobility, and need for assistance with personal care. Her discharge MDS showed a BIMS score of 14, indicating intact cognition, and she required supervision with showering, used a manual wheelchair, and was frequently incontinent of bowel and bladder. Her care plan reflected that she wished to return home and included discharge planning interventions involving the resident, family/caregivers, and community resources. The record showed a Statutory Durable Power of Attorney naming FM A as the primary agent and FM B as the alternate agent, with FM B authorized to act only if FM A failed or ceased to act. The resident’s NOMNCs showed Medicare coverage ended, and the resident remained in the facility while discharge planning continued. On the day of discharge, RN C documented that FM B requested discharge, the DON was notified, and the resident left with family members in good condition with discharge instructions and medications. RN C stated she did not notify FM A before or after the discharge because FM B was also a POA. During interviews, FM A stated he was the primary POA, wanted the resident to remain at the facility until a reliable home health arrangement was in place, and was not consulted before or after the discharge. He said he learned of the discharge only when FM B took the resident home and stated he would not have authorized FM B to take her home. The SW and ADON both stated there were family dynamics between FM A and FM B and that FM A was more involved in the resident’s care and preferred she remain at the facility. The DC and DON stated the resident was discharged with FM B and that FM A was not contacted, with the DON stating she believed FM B was the designated POA despite the POA document identifying FM A as primary. The facility policy required the resident representative to be involved in discharge planning and informed of the final plan.
Unsafe discharge planning and failure to involve the primary POA
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for a resident who had been admitted with pneumonia, anemia, major depressive disorder, muscle weakness, reduced mobility, and need for assistance with personal care. Her discharge MDS showed a BIMS score of 14, supervision needed with showering, use of a manual wheelchair, and frequent bowel and bladder incontinence. Her care plan reflected that she wanted to return home and included discharge planning interventions such as establishing a pre-discharge plan with the resident and family/caregivers, arranging community resources, providing contact numbers for referrals, and providing staff support. The resident’s record showed Medicare coverage ended after notices of non-coverage were issued, and a progress note documented that on the day of discharge, FM B requested discharge, the DON was notified, and the resident was sent home with medications and discharge instructions. The note stated the resident left with family members in good condition. However, interviews showed the facility did not verify the discharge destination or adequately clarify who had authority in the family decision-making process. The SW stated he did not consult FM A regarding the discharge plan and was unaware of the condition of the residence or whether an elevator was available. The DC also stated he did not verify whether FM B actually lived in an apartment, despite being told that the resident would go there. The interviews further showed conflicting information about the resident’s living arrangement and the family’s roles. FM A stated he was the primary POA, that he wanted the resident to remain at the facility until a reliable home health arrangement could be organized, and that he was not consulted before the discharge. FM B stated she wanted to take the resident home and said the resident lived in her own house, while staff members variously believed the resident was going to an apartment or a flat on the second floor. The DON stated she believed FM B was the POA #1 and did not think it was necessary to inform FM A because he lived in another city, even though the POA document identified FM A as the primary POA and FM B as the alternate. The facility policy required sufficient preparation and orientation, consideration of caregiver capacity, and involvement of the resident and resident representative in the discharge plan, and the resident admission agreement required prior notification for a proper discharge.
Expired Supplies Found in Medication Room
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when expired medical supplies were found in the 100/200-hall medication room during observation. The expired items included a 24G x 3/4 in. safety IV catheter with an expiration date of 03/31/2024, a disposable syringe without needle with an expiration date of 11/10/2024, a 20G x 1 in. safety IV catheter with an expiration date of 12/22/2024, three 1-ml tuberculin safety syringes with needle with expiration dates of 12/31/2024, and two hypodermic needles 25G x 0.625 with expiration dates of 07/16/2025. During interviews, MA A stated the ADON was responsible for checking for expired medications and supplies in the 100/200-hall medication room and that expired supplies should not be used on residents. The ADON stated she checked the medication room daily during morning rounds and that the DON followed behind her to ensure completion of her work. The DON stated the medication aides were responsible for checking for expired medications and supplies daily and that the ADON was responsible for following up to ensure none remained in the medication room. The ADMIN stated she expected the nurses and ADON to check the medication room daily. The facility policy stated outdated, contaminated, or deteriorated medications and supplies are to be immediately removed from stock.
Failure to Provide and Document Specialized PASRR Services and Equipment
Penalty
Summary
The facility failed to provide specialized habilitation services and did not obtain specialized durable medical equipment for a resident identified as needing such services through the PASRR (Preadmission Screening Resident Review) process. The resident, a male with multiple diagnoses including intellectual disability, cognitive communication deficit, and developmental disorder, was admitted with a PASRR positive status. His care plan indicated the need for specialized services, including a customized wheelchair and mattress, as determined by the IDT (Interdisciplinary Team) meeting. However, the IDT meetings did not address the use of a supportive mattress, and the facility did not request a customized mattress within the required 20 business days after the IDT meeting. Interviews with facility staff revealed that although the need for a customized mattress was discussed, it was not documented in the resident's records or in the facility's portal profile. The Director of Rehabilitation (DOR) acknowledged that the mattress was not ordered due to safety concerns related to another resident, but this rationale was not documented. The PASRR Program Specialist confirmed that the facility did not submit the necessary forms within the required timeframe and failed to document the reasons for the delay, which is required for compliance. The facility's own PASRR policy and procedure require coordination with the local authority, timely documentation, and provision of specialized services as recommended in the Level II evaluation. In this case, the facility did not document the provision or delay of the specialized mattress, nor did it ensure that all recommended services were addressed and provided within the mandated timeframe, resulting in a deficiency.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to establish and follow a written policy on permitting residents to return after hospitalization or therapeutic leave, specifically in the case of a resident who was sent to a behavioral health hospital. The resident, a female with severe cognitive impairment and multiple mental health diagnoses, was discharged to a psychiatric hospital without sufficient preparation for an orderly discharge. The facility did not provide a 30-day discharge notice to the resident or her family, and there was no documented discussion with the resident's responsible party about the behavioral hospital placement until the day of the transfer. The resident had a history of escalating behaviors, including self-harm and aggression towards staff and other residents. The facility's social worker and DON noted that the resident's behaviors had become increasingly difficult to manage, and the facility's psychiatrist had maxed out on medication options. Despite previous hospital recommendations for a memory care unit, the facility did not have such a unit, and the resident's responsible party was not interested in transferring her to another facility. The facility staff believed that the psychiatric hospital would assist in finding a suitable placement for the resident after her treatment. The facility's ADM stated that the expectation for the discharge process was to provide a bed-hold notice, review hospital updates, and readmit residents if their needs could still be met. However, in this case, the facility determined that the resident was no longer appropriate for their care and required a higher level of care with daily in-house psychiatric services. The facility's policy indicated that if a resident could not return, it constituted a discharge, but the facility did not follow the proper discharge procedures as outlined in their policy.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that the call light systems in the bathrooms and shower areas of two residents were operational. On the day of the survey, it was observed that the emergency call lights next to the toilet and in the shower for these residents were not functioning. Interviews with the residents and their representatives revealed that the call lights had been non-functional for about a month, and despite attempts to repair them, they remained inoperable. This deficiency was identified as Immediate Jeopardy (IJ) due to the potential risk it posed to the residents' safety and well-being. The maintenance staff acknowledged ongoing issues with the call light systems, which had persisted for several months. The maintenance supervisor admitted to having problems with call lights in residents' rooms and stated that the issue had been ongoing for the last six months. Despite monthly testing and troubleshooting efforts, the call lights in the affected residents' rooms were not functioning properly. The facility had recently changed the call light company, but the problems persisted, and the call light testing system did not indicate the inoperability of the call lights in question. Interviews with various staff members, including CNAs, LVNs, and the Administrator, revealed a lack of awareness and communication regarding the non-functioning call lights. Some staff members were unaware of the issue, while others mentioned alternative measures such as providing call bells and increasing rounds to compensate for the non-functional call lights. However, these measures were not consistently implemented, and there was a lack of documentation and follow-up to ensure that the residents' needs were being met adequately.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy. Observations revealed that the nasal cannulas and tubing for these residents were not properly stored when not in use, which could lead to cross-contamination and illness. Specifically, the tubing and nasal cannulas were found sitting on bedside tables, dressers, and recliners, rather than being bagged and stored appropriately. Resident #5, a female with severe cognitive impairment and a need for oxygen therapy, had her nasal cannula and tubing left on her bedside table. Resident #36, a male with moderate cognitive impairment, also had his nasal cannula and tubing left on his bedside table. Resident #77, a female with severe cognitive impairment and a need for oxygen therapy, had her oxygen tank not in use, yet the tubing and nasal cannula were left on her dresser and recliner. Interviews with staff, including RNs, LVNs, CNAs, and the Director of Nurses, revealed a lack of awareness and adherence to proper storage procedures for oxygen equipment. Although staff were trained to bag and date the tubing and nasal cannula when not in use, they were unaware that the equipment for these residents was not stored properly. The facility did not have a specific policy on the storage of oxygen tubing and nasal cannula, contributing to the oversight.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitation, as observed during a survey. Kitchen staff did not properly secure their hair with hairnets, leaving parts of their hair uncovered, which could lead to contamination. Observations revealed that the ice machine had black spots on its inner ceiling, indicating a lack of proper cleaning and maintenance. Additionally, expired food items were found in the walk-in refrigerator, including jars of mayonnaise, Caesar salad dressing, ranch dressing, and lime juice, which were not discarded as required. The walk-in freezer was also found to be in poor condition, with a buildup of ice on the bottom of the freezer unit. This ice buildup was attributed to the freezer door not being securely closed, as explained by the Dietary Manager (DM). The DM stated that maintenance had installed a latch on the freezer door to address this issue, but there was no documentation or logs to confirm regular checks or discarding of expired items. The DM admitted to not being aware of the expired food items in the refrigerator and acknowledged the risk of residents becoming ill from consuming expired food. Interviews with kitchen staff revealed that they were aware of the requirement to wear hairnets at all times, yet some staff members were observed not complying with this policy. The DM confirmed that there were no maintenance records for the ice machine and no cleaning sheets for the freezer unit. The facility lacked policies on food storage, discarding expired food, and cleaning the freezer unit, which contributed to the deficiencies observed during the survey.
Incomplete Advanced Directives for Two Residents
Penalty
Summary
The facility failed to ensure the proper completion and validation of advanced directives for two residents, leading to potential risks of not honoring their medical wishes. Resident #50's out-of-hospital do-not-resuscitate (OOH-DNR) form was incomplete, lacking the resident's printed name and date signed, despite the resident's care plan and physician's orders indicating a DNR status. Interviews with the resident and staff confirmed the missing information, and the facility's social worker acknowledged the oversight but did not provide a solution. Similarly, Resident #71's Medical Power of Attorney (MPOA) was incomplete, missing the necessary signatures and witness or notary acknowledgment, rendering it invalid. The social worker admitted the document was incomplete and lacked a signature page, which was necessary for validation. The Director of Nursing and Administrator both confirmed that the advanced directives were not valid without the required signatures and dates, as per the facility's policy and state health codes.
Failure to Include Diagnoses in Resident Assessments
Penalty
Summary
The facility failed to complete comprehensive, accurate, and standardized assessments for two residents, which could potentially place them at risk of not having their care and treatment needs properly assessed. For one resident, the comprehensive assessment did not include a cancer diagnosis, despite the presence of a physician's order for Anastrozole, a medication indicated for breast cancer. The resident's care plan also lacked information regarding the cancer diagnosis. This oversight was identified through a review of the resident's face sheet, MDS assessment, and physician's orders. For another resident, the comprehensive assessment failed to include a depression diagnosis, even though the resident was prescribed Amitriptyline and Mirtazapine for depression. The resident's care plan did reflect a focus on antidepressant medication use related to the depression diagnosis. Interviews with the MDS coordinator, DON, and ADM confirmed that the MDS assessments should accurately reflect the residents' diagnoses and that the facility follows the RAI manual. The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual emphasizes the importance of documenting active diagnoses on the MDS, such as cancer and psychiatric/mood disorders.
Failure to Conduct PASRR Level II Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents requiring a Pre-Admission Screening and Resident Review (PASRR) Level II assessment received one, specifically in the case of a resident with mental illness. The resident, who was admitted with diagnoses including schizophrenia and bipolar disorder, did not have a positive PASRR Level I screening, which should have triggered a Level II evaluation. The PASRR Level I screening incorrectly indicated no mental illness, despite the resident's documented diagnoses and physician's orders for medication related to schizophrenia. Interviews with facility staff, including an LVN and the MDS coordinator, revealed that the PASRR Level I screening was not corrected upon admission, even though the resident's mental health diagnoses were known. The Director of Nursing (DON) and the Administrator acknowledged the facility's process for identifying residents with mental illness was not followed, leading to the oversight. The facility's policy required a designated individual to ensure all residents with a positive PASRR Level I screening received a Level II evaluation, which was not done in this case.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, three residents were observed with unclean nails, which were not addressed by the staff. Resident #20, a female with severe cognitive impairment and requiring assistance with personal hygiene, was found with a blackish substance under her fingernails. Despite her need for assistance, her care plan's intervention to check and clean nails on bath days was not followed. Resident #39, a male with moderate cognitive impairment and requiring assistance with ADLs, also had a blackish substance under his fingernails. He had requested nail cleaning from a staff member, who promised to do it later but did not return. This indicates a failure in staff responsiveness to resident requests for personal hygiene assistance. Resident #39's care plan required assistance with bathing and dressing, but his nail care needs were neglected. Resident #72, a male with severe cognitive impairment and diabetes, was found with uneven and dirty nails. His care plan specified that his nails should be cut straight across and filed to prevent rough edges, but this was not done. Interviews with staff, including CNAs and the Director of Nurses, revealed that nail care was supposed to be part of the residents' shower routine or done as needed. However, the staff failed to provide this care, leading to the observed deficiencies in personal hygiene for these residents.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation - North | 2.3 mi | ★★★★★ | 11 | 2 |
| Coral Rehabilitation And Nursing Of Austin | 3.3 mi | ★★★★★ | 52 | 10 |
| Oakcrest Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 8 | 0 |
| Heritage Park Rehabilitation And Skilled Nursing C | 4.3 mi | ★★★★★ | 8 | 1 |
| Gracy Woods Ii Living Center | 4.4 mi | ★★★★★ | 0 | 0 |
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