Health inspection·November 29, 2023

F 0825 Provide or get specialized rehabilitative services as required for a resident. 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 provide specialized rehabilitative services for 1 of 4 residents reviewed for specialized rehabilitative services. (Resident #1) Residents Affected - Few The facility failed to ensure Resident #1 received speech therapy per the PASRR Comprehensive Service Plan January 2023 to March of 2023. This failure could place residents who require specialized rehabilitative services at risk of decline in health status and a decreased quality of life. Findings included: Record review of a face sheet dated 11/28/2023 indicated Resident #1 was an [AGE] year-old female who had a initial admit date of 01/16/2014 readmission to the facility on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), hypertension (high blood pressure), and depressive disorder. Record review on 11/28/2023 of Resident #1's Order Summary dated 11/28/2023 indicated no order for speech therapy. Record review of the MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated cognitively intact. The MDS indicated Resident #1 required limited assistance from staff for activities of daily living. The MDS did not indicate Resident #1 was receiving speech therapy. Record review of a care plan revised on 07/07/2023 indicated Resident #1 had cerebral palsy (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscle). The Care Plan did not indicate/address speech therapy. Record review of the MDS - Resident Assessment and Care Screening Nursing Home Quarterly dated 09/08/2023 Record review on 11/28/2023 of Resident #1's electronic health record indicated no speech therapy notes for January 2023 through March of 2023. Record review on 11/29/2023 of PASRR (Pre-admission and Resident Review) Comprehensive Service Plan dated 01/17/2023 indicated a continuation of speech therapy services. Page 1 of 2 675553 675553 11/29/2023 Quitman Wellness & Rehabilitation 1026 E Goode St Quitman, TX 75783

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the PASSAR Nursing Facility Specialized Services (NFSS) (a request for therapy services) with the assessment date of 03/09/2023 for speech therapy submitted on 03/21/2023. The facility was unable to provide any previous NFSS form. During an interview on 11/29/2023 at 11:39 AM., with the Director of Rehabilitation Therapy said Resident #1 should have continued speech therapy services on or about 1/17/2023 per the Interdisciplinary Team meeting. The Director of Rehabilitation Therapy said she was not able to locate any speech therapy notes or authorizations from January - March of 2023. The Director of Rehabilitation Therapy said she had become employed with the facility approximately two months ago. The Director of Rehabilitation Therapy stated she would not be able to explain why these services were not given appropriately. The Director of Rehabilitation Therapy said Resident #1 should have been getting services because she was PASSAR positive. The Director of Rehabilitation Therapy stated it was her job to ensure the authorization request was completed for the rehabilitation services. The Director of Rehabilitation Therapy said when the facility did not have a therapist, she would request a therapist from a sister facility to fulfill the need. The Director of Rehabilitation Therapy stated the importance in providing the services timely was to prevent decline in resident status and to promote a healthy outcome for the residents. During an interview on 11/29/2023 at 12:15 PM., the DON said she was not able to locate any speech therapy evaluation, notes or authorizations/orders during January 2023 to March of 2023. The DON said Resident #1 should have received continued speech therapy services on or about 1/17/2023 per the Interdisciplinary Team meeting. The DON stated the facility did not have a speech therapist during January 2023 to March of 2023. The DON said the Director of Rehabilitation Services should have contracted out these services to prevent the resident from going without therapy which could have resulted in a decline of health status. During an interview on 11/29/2023 at 03:15 PM., the Administrator said he expected the Director of Rehabilitation Therapy to complete authorization requests for rehabilitation services. During January 2023 to March of 2023, the facility had several changes in the Director of Rehabilitation Therapy, and because of this Resident#1's speech therapy referral must have fallen through the cracks. The Administrator said was without a speech therapist during January 2023 to March of 2023 also. The Administrator said he expected the facility to communicate that need to a sister facility and/or borrow/contract a speech therapist to prevent any decline of residents. Review of Requests for Therapy Services policy with a revised date of April 2007 did not address speech therapy referrals after the PASSAR recommendations. 675553 Page 2 of 2