Health inspection·June 11, 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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for one of four residents (Resident #1)reviewed for PASRR services . The facility failed to submit a NFSS request form for PASRR Specialized Services within 20 business days after PASRR Comprehensive Service IDT Meeting on 12/23/2024. This failure could place residents at risk of not receiving needed individualized care, and specialized services to meet their needs. Findings include: Record review of Resident #1's face sheet, dated 06/11/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Parkinson's disease without dyskinesia, and without mention of fluctuations (did not experience involuntary, erratic movements and there are no documented variations in the severity of their symptoms) and , autistic disorder (a neurodevelopment condition characterized by persistent challenges in social communication and interaction, along with restricted, repetitive patterns of behavior, interests, or activities). Record review of Resident #1's MDS , dated 02/15/2025, reflected Resident #1 had a BIMS score of 15, which indicated his cognition was intact. Resident #1 was independent with eating, oral hygiene, toileting, upper and lower body dressing, and personal hygiene. He required supervision with showers. Record review of Resident #1's MDS , dated 04/15/2025, reflected Resident #1 had a BIMS score of 15, which indicated his cognition was intact. Resident #1 was independent with eating, oral hygiene, toileting, upper and lower body dressing, and personal hygiene. He required supervision with showers. Record review of Resident #1's Comprehensive Care Plan, with revision date 12/18/2024 , reflected Resident #1 was PASRR positive. Interventions, revised on 12/18/2024: Provide specialized physical therapy. Provide specialized speech therapy. Provide specialized occupational therapy. Record review of Resident #1's PASRR Comprehensive Service Plan Form, dated 12/23/2024, reflected evaluation for PT and OT was needed. The following was in attendance of the Meeting: Resident #1, PASRR Coordinator, Social Worker, MDS Coordinator and Director of Therapy. Page 1 of 3 455351 455351 06/11/2025 Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Requested Resident #1's PASRR Comprehensive Quarterly Service plan form, due on March 2025 via email to PASRR Coordinator and it was not provided at time of exit. Record review of Email from PASRR QM to the DON and Administrator, dated 04/17/2025, reflected The reason for this email is to notify you that according to our records, an Interdisciplinary Team meeting (IDT) was held and entered the Long-Term Care Online Portal for one or more of your residents. During the IDT meeting nursing facility specialized services were recommended and agreed upon for the resident in your facility. For your facility to be in compliance with the 26 Texas Administrative Code (TAC), Chapter 554, Subchapter BB, section §554.2704(i)(7), a nursing facility must .initiate nursing facility specialized services within 20 business days following the date that the services are agreed to in the IDT meeting . Currently, your nursing facility is out of compliance as per this TAC Rule. If the resident is still in your nursing facility, you must submit a request for the PASRR specialized services agreed to during the IDT meeting within 3 business days for therapies of receiving this email. (This was referring to Resident #1 ). Interview on 06/11/2025 at 10:30 AM, the Director of Therapy stated she attended a meeting in December 2024 with the PASRR Coordinator concerning Resident #1. She stated the IDT (Social Worker, MDS Coordinator, PASRR Coordinator, Director of Therapy) during the meeting decided Resident #1 would benefit from Occupational and Physical therapy to build his endurance. She stated Resident #1 did not receive OT or PT until 05/01/2025 . She stated there was a possibility if a resident did not receive therapy from December 2024 until May 2025, the resident may have a decline in ADLS. She stated Resident #1 was at his baseline with his ADLs and did not have a decline from December 2024 until he began therapy May 2025. The Director of Therapy stated she did ask the PASRR Coordinator if the therapy had been approved prior to April 2025. She did not recall the exact date. The Director of Therapy stated she was aware paperwork was required to be completed for approval with PASRR . She stated she did not recall if she discussed Resident #1's approval for therapy with anyone at the facility. Interview on 06/11/2025 at 10:50 AM, the MDS Coordinator stated the IDT team had an Annual meeting with Resident #1 and the PASRR Coordinator on 12/23/2024 discussing his care. She stated PT and OT was discussed during this meeting and the IDT team decided Resident #1 would benefit from therapy (PT and OT). The MDS Coordinator stated Resident #1's Responsible Party was on the phone during the meeting and was included in the PASRR meeting. She stated the PASRR Comprehensive Service Plan was submitted to Simple LTC (electronic medical record for PASRR information). The MDS Coordinator stated she was not aware of NFSS forms and believed this was the only step she was required to do when requesting services from PASRR. She stated she consulted with the PASRR Coordinator with any updates on Resident #1's approval for PT and OT. The MDS Coordinator stated she did not recall the date she spoke to the PASRR Coordinator. She stated the DON forwarded her an email dated April 2025 with information on Resident #1's therapy from the PASRR office. The MDS Coordinator stated she was not aware of the NFSS forms to be filled out and submitted to PASRR. She stated the DON instructed her how the process of filling out the NFSS forms and to submit these forms in the Simple electronic system for PASRR. She stated she spoke with the Director of Therapy, and they filled out the forms between 05/01/2025 and 05/03/2025. She stated the therapy department completed PT and OT assessments on Resident #1 to be submitted with the NFSS forms. The MDS Coordinator stated Resident #1 began therapy the first week of May 2025. She stated she did not receive training on NFSS forms and the process of submitting all the paperwork to PASRR when requested services for a resident. Attempted interview on 06/11/2025 at 11:35 AM with PASRR Coordinator via phone was unsuccessful. She did not return the phone call. 455351 Page 2 of 3 455351 06/11/2025 Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/11/2025 at 11:45 AM, the Director of Nurses stated the protocol after a PASRR Comprehensive Plan meeting, if it was determined a resident needed therapy services or medical equipment was to complete all evaluations required and to document on the NFSS forms. She stated this information was required to be submitted within 20 days of the PASRR Comprehensive Plan Meeting to Simple LTC. The Director of Nurses stated if the NFSS was not completed the resident would not receive services or equipment. She stated Resident #1 PASRR Comprehensive Plan meeting was held on 12/23/2025 and the team during the meeting decided Resident #1 needed PT and OT. She stated the NFSS was not submitted, and she did not follow up to ensure all the paperwork was submitted for Resident #1 to receive these services. The Director of Nurses stated she did not have any paper work showing the MDS Coordinator received training on the process of NFSS and how to submit the appropriate documentation for approval from PASRR. She stated she was not the MDS department supervisor, and it was not her responsibility. She stated the Administrator was MDS supervisor. The Director of Nurses stated the MDS Coordinator began working at the facility in November 2024. The Director of Nurses stated she did not read the email sent to her on 04/17/2025 by the PASRR QM until approximately 2 weeks later. She stated when she did read the email, she did not read the information where it stated the NFSS paper work was expected to be completed within 3 days of receiving the email. She stated she forward the email to the MDS Coordinator, and she explained to the MDS Coordinator what forms were required to be completed by her and the Director of Therapy. She stated the forms were filled out and the MD signed the forms and Resident #1 began his therapy the first week in May 2025. The Director of Nurses stated Resident #1 did not have a decline in his ADLs from December 2024 until he began therapy in May 2025. She stated he was at his baseline. She stated there was a potential if a resident needed OT and PT services and did not receive these services, a resident ADLS may decline. The Director of Nurses stated the facility did not have a policy or protocol for PASRR. Interview on 06/10/2025 at 12:30 PM, Resident #1, stated he was feeling great, and he completed care without assistance except with showers and he needed someone to help him gathering all the things he needed to take a shower. He stated he had not had any changes in doing anything for himself. Interview on 06/10/2025 at 12:50 PM, the Administrator stated the MDS Coordinator was responsible to complete all documents for any services for PASRR. He stated if a resident waited from December 2024 until May 2025 to receive PT and OT, there was a possibility the resident may decline in his ADLS and physical mobility. He stated he did expect the DON to read emails and follow up with the appropriate staff to ensure all the information in the email was completed. The Administrator stated he was the MDS Coordinator supervisor, and he did not know how the paper work on Resident #1 was missed. Interview on 06/10/2025 at 1:25 PM, CNA A stated she had worked at the facility approximately two years. She stated she had been assigned to Resident #1 several times per week from December 2024 until May 2025. CNA A stated his ADL performance was at his baseline during those months. She stated there were no changes in his ADLs. Interview on 06/10/2025 at 1:40 PM, CNA B stated she had been assigned to Resident #1 numerous times per month from December 2024 until May 2025. She stated Resident #1 was independent with his ADL care except he needed supervision with his showers. She stated Resident #1's ADLs had not declined from December 2024 until May 2025. CNA B stated Resident #1 remained at his baseline. Interview on 06/10/2025 at 9:35 AM The DON stated the facility did not have a PASRR policy. 455351 Page 3 of 3