Health inspection·April 10, 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 PASRR level II recommendations into a resident's assessment and care planning to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs for one (Resident #1) of three residents reviewed for PASRR (Preadmission Screening Resident Review) services. The facility failed to submit the Nursing Facility Specialized Services for SLP, PT, OT, and a customized wheelchair within 20 business days after the IDT meeting for Resident #1. This failure could place residents at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture), epilepsy (seizures), unspecified intellectual disabilities, dysphagia (difficulty with swallowing), and weakness. Review of Resident #1's quarterly MDS assessment, dated 02/05/25, reflected a BIMS score of 00, indicating he had a severe cognitive impairment. Review of Resident #1's quarterly care plan, revised 10/09/24 reflected he had been identified as having PASRR positive status related to an intellectual disability and/or developmental disability with interventions of providing habilitative OT, PT, and SLP and a CMWC. Review of Resident #1's IDT Care Conference, dated 10/16/24, reflected the following summary: Annual PASSR meeting . Resident/RP has chosen to continue PASRR specialized services PT/OT/ST and Hab Co. Therapy arrange evaluation for CMWC. Review of Resident #1's Habilitation Service Plan, dated 10/23/24, reflected the following: Section 4, Habilitation Coordination Plan: [Resident #1] will receive habilitation coordination while the individual is residing in the Page 1 of 3 675797 675797 04/10/2025 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0644 Level of Harm - Minimal harm or potential for actual harm nursing facility (NF). In accordance with the requirements in the rule and handbook, the SPT has determined the habilitation coordinator (HC) will meet face-to-face with [Resident #1] List all activities to be coordinated or monitored by the HC, including NF Preadmission Screening and Resident Review (PASRR) support activities. Residents Affected - Few 1 Monitor the specialized services provided to the individual to determine whether progress toward achieving goals and outcome(s) is being made. 2 Facilitate the coordination of the HSP and the NF Comprehensive Care Plan. . Physical Therapy will help [Resident #1] improve his position in his wheelchair. Occupational Therapy will help [Resident #1] with his upper body extremities. Speech Therapy will help [Resident #1] with communicating his needs. Swallowing test in order for him to be able to have pleasure food by month [sic]. CMWC will help [NAME] to be comfortable while sitting in the common area with other individuals. During an interview on 04/10/25 at 9:30 AM, the MDSC stated when a resident who was PASRR positive, the facility scheduled an interdisciplinary team meeting that included the HC. In that meeting they determined what services would benefit the resident. The information gathered in that meeting was entered into the computer system. The NFSS form was completed by the DOR and entered into the computer system. She stated the NFSS for Resident #1 was not accepted multiple times for assorted reasons. She stated she had reached out to her PASRR contact person and to HHSC PASRR support multiple times. During an observation and attempted interview on 04/10/25 at 10:34 AM, revealed Resident #1 sitting in a high-back wheelchair in the day room. He did not respond when spoken to . During an interview on 04/10/25 at 10:40 AM, the MDSC stated the NFSS forms were supposed to be submitted 20 or 21 days after the care plan meeting. She stated she and the DOR received alerts when the NFSS forms were not accepted in the system. During a telephone interview on 04/10/25 at 10:53 AM, the PASRR Program Specialist stated when a resident was admitted and was PASRR positive, an IDT meeting was held, and services were recommended. The facility then had 20 business days to send the NFSS out for approvals. She stated Resident #1's facility did not send the form within 20 business days. She stated that was when she sent out a courtesy email encouraging compliance. She stated if she received no response from that, she then made a complaint to HHSC. She stated if services were approved and a resident went to the hospital, the process would start over once they were readmitted . She stated but the bottom line was Resident #1's trip to the hospital had nothing to do with the facility sending the form within 20 days. During an interview on 04/10/25 at 12:50 PM, the ADM stated he was new to the facility but at is last facility, the SW and MDSC would get started on the PASRR referrals right away after a resident 675797 Page 2 of 3 675797 04/10/2025 Avir at Weston 2505 S 37th St Temple, TX 76504

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was admitted . His expectations were that they were done timely. He stated a resident could suffer if they did not get the paperwork done and they did not get the services they requested. Review of the facility's PASRR Policy, dated 04/26/16, reflected the following: The facility will initiate the request for specialized services within 20 business days of the IDT meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal. 675797 Page 3 of 3