Health inspection·November 16, 2023

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 coordinate assessment with the preadmission screening and resident review (PASSR) program to the maximum extent practicable to avoid duplicative testing and effort which included incorporating the recommendation from the PASSR level II determination into the resident assessment, care planning and transition of care for one (Resident # 1) of one resident reviewed. The facility failed to provide specialized service to Resident # 1 due to the facility not submitting the Nursing Facility Specialized Services (NFSS) request form in the Simple LTC portal. This failure could place residents at risk of not receiving necessary care of specialized service which could diminish the residents' quality of life and highest level of functioning. Finding include: Review of Resident #1 face sheet dated 11/15/2023 revealed a [AGE] year old male admitted on [DATE] and discharged on 09/30/2022 with diagnoses that included unspecified intellectual disabilities ( a developmental disorder, characterized by less than average intelligence and significant limitations in adaptive behavior with onset before the age of 18), Acute on Chronic systolic (congestive) heart failure ( active symptoms of heart problems or diseases can lead to heart failure which is a long -term condition ), . Cognitive Communication deficit (difficulty with thinking and how someone uses language) and Unsteadiness on feet (Gait and balance issues can cause unsteadiness and difficulty standing and walking). Review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 9 (8 to 12 points suggest moderate cognitive impairment). Review of Resident # 1's PASSR level I screening dated 8/12/2023 shows positive for intellectual disorder. Review of Resident # 1's care plan shows indication dated 8/23/2023 show PASSR positive resident. Review of Resident # 1's medical records revealed physical, occupational, and speech therapy services under part B services from 9/4/2023 through 9/24/2023. Resident # 1 was discharged from Physical, occupational, and speech services on 9/23/2023. No physical, occupational, or speech therapy services were received from 09/24/2023 through discharge date of 09/30/2023. Review of Resident #1's IDT team meeting dated 08/25/2023 that included LIDDA representative, team Page 1 of 2 455983 455983 11/16/2023 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0644 determined individual would benefit from HAB coordination, PT, OT, ST, and independent living skills. Level of Harm - Minimal harm or potential for actual harm Review of Policy completing the NFSS form for a Habilitative therapy assessment dated April 2021 revealed Once the assessment has been performed, the nursing facility must submit the request through the LTC online portal no more than 30 days from the date it was preformed by the therapist. Residents Affected - Few Interview with the RN MDS nurse on 11/16/2023 1:30 pm, stated that she was present at the IDT meeting on 8/25/2023 where plan for Resident # 1 was discussed. Resident was admitted under Medicare part B and she did not submit a NFSS as she thought since he was receiving services it was not needed. When Resident # 1's medical conditions changed, and he could no longer participate in therapies under Medicare Part B, the resident transferred to the hospital, and did not return prior to completing the paperwork. She stated it is part of her job as MDS nurse to coordinate services with the local authority. She uses facility policy and state guidelines as reference. She stated she thought she had 30 days from the last day of service not from the determination from the need of services. Interview with the DON on 11/16/2023 2:00 PM, he stated he was not aware the forms were not submitted, nor was he aware that an attempt was made to contact the facility. He stated that the MDS nurse is responsible for coordinating with the local authority, but the IDT is responsible for the implementation and oversite. He stated his expectation was that all residents receive the services they need to improve their quality of life. He stated that if a resident did not receive these services a potential negative outcome would be not maintaining the current level of function. Interview with the ADM on 11/16/2023 2:30 pm, her expectation was that all the residents were assessed, and services needed be provided. She stated a resident who does not receive the needed services can have a potential in decreased quality of life 455983 Page 2 of 2