Health inspection·June 5, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #36) reviewed for PASARR Level 1 screenings. Residents Affected - Few The facility failed to notify the local authority of the PASARR I screen for Residents #36. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a Face Sheet dated 06/05/25 for Resident #36 revealed a [AGE] year-old female admitted initially to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included post-traumatic stress disorder (is a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it), bi-polar disorder, in full remission, most recent episode depressed (is a serious mental illness characterized by severe mood swings. Remissions refers to a state where mood symptoms are absent or minimal), Parkinson's disease without dyskinesia, without mention of fluctuations (the condition in its state where these involuntary movements are not present), other insomnia (sleep difficulties that do not link to any other health conditions. It can be acute or chronic). Record review of Resident #36's diagnosis report revealed that she was diagnosed with post-traumatic stress disorder upon admission and bi-polar disorder, in full remission on 03/13/23. Record review of Resident #36's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated cognitive intact in section C. Record review of Resident 36's care plan dated 03/24/2025 revealed a focus that Resident #36 had a trauma r/t history of PTSD; she had mood problems related to the disease process; and she has the potential to demonstrate physical behaviors related thx of PTSD. With a goal of no evidence of emotional, physical, and psychological problems; improved mood state and happier, calmer, appearance, no s/sx of depression, anxiety, or sadness; effective coping skills through the review date. Interventions in place were to administer mediations as ordered, monitor/document for side effects and effectiveness, behavioral health consults as needed, encourage resident to attend care conference to express preferences and participate in care plan process, monitor/record/report to MD mood patterns s/sx of depression, anxiety, or sad mood. Page 1 of 2 455637 455637 06/05/2025 Wellington Rehabilitation and Healthcare 1802 S 31st Temple, TX 76504

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #36's PASARR Level 1 Screening dated 03/13/23 revealed the resident did have a Mental Illness, Intellectual Disability, or Developmental Disability in section C. During an interview with the MDS Coordinator on 06/06/2025 at 2:25 PM, reflected she does the MDS for the residents and the resource nurse reviews it to make sure it is correct. She stated if it is done incorrectly, she can go in, complete the modification, and sign it. She stated failure to enter the PASARR request in a timely manner could result in the resident not receiving the psych services and not get some DME they may have qualified for. She has submitted a Negative PASARR Level 1 form 1012 for resident dated 6/6/2025. During an interview with the ADM on 06/06/2025 at 2:40 PM, reflected his expectation is to clarify and place his trust in his team to meet the expectations and communicate any needs. He expected them to communicate with the family on how the resident are doing. He stated the MDS Coordinator and the MDS clinical resource is responsible for making sure the MDS are accurate. He stated not submitting the PASARR in a timely manner to the local authorities, this failure could result in the resident not receiving services. Record review of the facility's policy, PASRR Policy and Procedure undated reflected: Policy: The facility will designate as individual to follow up on ALL residents have receive a PASARR Level I screening. If the facility serves a resident with a positive PASARR Level I screening, the facility MUST have obtained a PASARR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASARR Level II evaluation. 455637 Page 2 of 2