Health inspection·April 30, 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 interview and record review the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASARR. The facility failed to initiate an NFSS within 20 business days following the date the services was agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. Findings included: Record review of the admission Record for Resident #1 documented a [AGE] year old female admitted to the facility 09/27/24 with a diagnoses of cerebral palsy (a group of neurological disorders that affect movement, balance, and posture often due to brain damage before, during or shortly after birth), major depressive disorder (a mental health condition characterized by persistent feelings of sadness and a loss of interest or pleasure), and anxiety disorder (a group of mental health conditions characterized by excessive worry, fear, and avoidance behaviors that significantly interfere with daily life). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. During an interview on 04/30/25 at 2:27 p.m., Resident #1, was asked how she liked therapy. Resident #1 was in the therapy room laying on a mat during the conversation after giving approval to talk with surveyor. Resident #1 stated it was OK but felt that life was generally boring since everything here is for old people. Resident #1 acknowledged that she was getting a new wheelchair. When asked if anyone from the PASARR local office ever took her out of the facility, she said no but stated she might like to go out. During an interview on 04/29/25 at 3:02 p.m., the MDS Coordinator stated they had the required IDT meetings with the local authority. There was a delay in getting Resident #1 started on therapy services and getting a new wheelchair since she had not been approved by Medicaid. The MDS Coordinator stated the facility was in contact with the case manager but her case was considered pending until her Medicaid was approved. The PASARR person in State Office was in contact with the Administrator and Director of Nurses but told them she would report the issue to regulatory since they did not start Page 1 of 2 675428 675428 04/30/2025 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0644 services within 20 days of the IDT meeting. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Rehabilitation (DOR) on 04/29/25 at 3:15 p.m., he stated that Resident #1 is now on all 3 therapies which included Physical therapy, Occupational therapy, and Speech therapy. The DOR stated they were going to start in October 2024 but had to wait until Resident #1's Medicaid was approved so she started services in February. Residents Affected - Few During an interview with the Administrator on 4/29/25 at 3:45 p.m., she stated she was communicating with the PASARR office until a new MDS Coordinator was hired in December. The ADM stated she tried to tell the PASARR office that they could not start services until Resident #1's LTCMI was showing that resident was approved for long term care Medicaid since PASARR is a Medicaid service. ADM stated that the MDS Coordinator who is now working will ensure that communication is maintained with the PASARR office. During an interview with the BOM on 4/30/25 at 11:25 a.m., the BOM stated the facility was waiting for Resident #1's Medicaid to be transferred from community Medicaid to Long Term Care Medicaid. Resident #1 was finally eligible for Medicaid in February 2025 so they were able to bill for Medicaid services including the custom wheelchair. During an interview with the LIDDA case manager on 04/30/25 at 3:56 p.m., stated if the facility is aware that Medicaid is not started, then we shouldn't put it in the system. When asked how a facility could prevent this situation which is resulting in a citation, the case manager said the service should have been put in TMHP as discontinued or pending until Medicaid was started. The case manager said they had offered ILS and Day Hab services to Resident #1 but so far she had refused. The case manager said they would continue to encourage her to take advantage of these services. The Administrator provided the admission Criteria policy dated March 2019 that included: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The State PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. 675428 Page 2 of 2