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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455412 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 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 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)