Health inspection·December 3, 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 interviews and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #1) of 3 residents reviewed for PASARR services and assessments. The facility failed to ensure Resident #1 received the Occupational Therapy that was recommended by the IDT meeting on 08/29/25. This failure placed residents at risk of not receiving needed specialized services that could impact their healing. Findings included: Review of Resident #1's Quarterly MDS Assessment, dated 10/04/25, reflected the resident had a BIMs score of 15 and was cognitively intact. She was admitted to the facility on [DATE]. Her diagnoses included seizure disorder, quadriplegia (inability to move extremities), anxiety, and depression. Review of Resident #1's Comprehensive Care Plan reflected there were no care plans for PASARR services. Review of Resident #1's PASARR Level 1 Screening, dated 06/27/25, reflected the resident tested positive for mental illness and developmental disability. Review of Resident #1's PASARR Comprehensive Service Plan Form reflected the initial interdisciplinary team meeting for the resident was held on 08/29/25 and Medicaid eligibility was confirmed. Review of Resident #1's Habilitation Service Plan dated, 08/29/25, reflected the initial IDT meeting was held on 08/29/25. Resident #1 was quadriplegic. Prior to her admission to the nursing facility, she was able to feed herself. Resident #1 wanted to be able to feed herself again. It was recommended that she receive occupational therapy to accomplish this goal. An interview on 12/03/25 at 12:40 PM with Resident #1 revealed she was not receiving all PASSAR services. She said she was supposed to receive occupational therapy. She said she did not know why she was not receiving the service. An interview on 12/03/25 at 2:48 PM with the MDS Coordinator revealed she was new to the position and was not familiar with Resident #1. She said she coordinated PASARR services. She said Resident #1 was not receiving occupational therapy but should have started receiving occupational therapy on 11/01/25, based on the Habilitation Service Plan and IDT meeting held on 08/29/25. She said she did not know why she was not receiving the therapy. The MDS Coordinator said the failures could result in a delay of care. An interview on 12/03/25 at 3:20 PM with the Rehabilitation Director revealed the occupational therapy was originally denied and another interdisciplinary team meeting was held. He said the new meeting was held on 11/19/25, (not reviewed), but the new request for occupational services was not sent by him, because the Physician was not available to sign the new request on 11/19/25. The Rehabilitation Director said on 12/05/25, the request would be sent again. He did not specify why he was waiting until 12/05/25 to re-send it. He said the risk to the resident would be a decline in functioning. An interview on 12/03/25 at 4:45 PM with the DON revealed the Physician was out on 11/19/25. She said he returned to the facility on [DATE] and the request for occupational therapy for Resident #1 should have been signed when the Physician returned. She said she did not know why the request was not signed and the MDS Coordinator was Page 1 of 2 455412 455412 12/03/2025 Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for sending the request. The DON said she would have to review Resident #1's records to determine what the risk to Resident #1 would be. Review of the facility's policy, Preadmission and Screening Resident Review (PASRR) Rules, revised 03/15/23, reflected: .2. The facility will initiate the request for specialized services within 20 business days of the IDT. meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal .3. The Social Worker or designee will document the IDT. minutes and all specialized services into the on-line portal. within 3 business days after the IDT.meeting and annually thereafter. 455412 Page 2 of 2