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 (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: 675428 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 675428 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064 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)