Health inspection·November 21, 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 interviews and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #1) of 3 residents reviewed for PASARR services and assessments. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team Meeting for Resident #1. This failure placed residents at risk of not receiving needed specialized services that could impact their healing.Findings included: Review of Resident #1's Annual MDS Assessment, dated 09/04/25, reflected the resident had a BIMs score of 13 and was cognitively intact. She was admitted to the facility on [DATE]. Her diagnoses included seizure disorder, schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), post-traumatic stress disorder, and mild intellectual disabilities. Review of Resident #1's Comprehensive Care Plan reflected there were no care plans for PASARR services. Review of Resident #1's PASRR Level 1 Screening, dated 05/21/25, reflected the resident tested positive for mental illness and intellectual disabilities. Review of Resident #1's PASARR Comprehensive Service Plan Form reflected the initial interdisciplinary team meeting for the resident was held on 06/11/25 and Medicaid eligibility was not found. An interview on 11/21/25 at 10:15 am with Resident #1 revealed she did not know if she was receiving PASARR services and did not know if she was supposed to be receiving PASARR services. An interview on 11/21/25 at 10:55 am with the MDS Nurse revealed he was new to the role of MDS Nurse. He said he did not know why the facility did not submit a complete and accurate request for nursing facility specialized services in the Long-Term Care Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. He said he did not know the date of Resident #1's interdisciplinary team meeting. He said he did not think the resident was receiving PASARR services and failure to submit documentation on the on-line portal could prevent the resident from receiving necessary services. He said he did not know what services the resident was supposed to be receiving. An interview on 11/21/25 at 12:10 PM with the DON revealed she thought Resident #1 was receiving PASSAR services. The DON said the resident was Medicaid pending and was waiting to get a new wheelchair and was scheduled to have a meeting on 12/04/25 to move to the community. The DON said the MDS Nurse was in charge of PASSAR services at the facility. The DON said she did not know why the facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. She said this failure could lead to depression and anxiety for the resident. An interview on 11/21/25 at 12:55 PM with the Regional Reimbursement Nurse revealed he did not know why the facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Page 1 of 2 675810 675810 11/21/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. He said on-line portal showed the resident had an IDT meeting on 06/11/25, but the facility did not submit the NFSS Request form. The Regional Reimbursement Nurse said the form would be submitted immediately. He said failure to submit the form could result in the resident not receiving appropriate services. A follow-up call was received from the Regional Reimbursement Nurse on 11/21/25 at 1:15 PM and he said Resident #1 did not have Medicaid and did not qualify for PASSAR services. Review of the facility policy, PASRR Level 1 Screen Policy and Procedure, revised 03/06/19, reflected: The IDT will determine which specialized services the resident will receive. After the IDT meeting, the NF must submit the information from the IDT meeting on the LTC Online Portal . 675810 Page 2 of 2