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 (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: 455983 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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)