Health inspection·November 19, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR evaluation report into a resident's care planning for 1 of 3 residents reviewed for PASRR assessments. (Resident #1) The facility did not provide and arrange for a specialized mattress for Resident #1 as recommended and agreed upon by the IDT on 6/10/25 within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services/DME that would enhance their quality of life. Findings included:1. Record review of the face sheet dated 11/19/25 indicated Resident #1 re-admitted to the facility on [DATE] with diagnoses including muscle weakness, quadriplegia (paralysis of all four limbs and torso leading to an inability to move and often walk), muscle spasm, and abnormal posture. Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #1 was at risk for pressure ulcers. Record review of the care plan last revised 4/14/25 indicated PASRR (screening to identify if resident has PASRR conditions serious mental illness, intellectual disability, developmental disability or related conditions) had identified Resident #1 in need of specialized services due to mental illness and TBI. The care plan indicated that specialized services would assist Resident #1 to achieve optimal functioning and recovery. Record review of the PCSP dated 6/10/25 for Resident #1 indicated that IDT recommended and agreed that Resident #1 required DME. PCSP indicated the DME required by Resident #1 was a specialized or treated pressure-reducing support surface mattress. During an interview on 11/18/25 at 10:22 a.m. with the Clinical Reimbursement Coordinator with PASRR, she said Resident #1 required DME services of a mattress. The Clinical Reimbursement Coordinator said once an IDT meeting had been held and it is determined a resident requires any kind of PASRR services the facility has 20 business days to submit a NFSS form. The Clinical Reimbursement Coordinator said per her records the NFSS form should have been submitted by the end of June 2025 or in Early July 2025. The Clinical Reimbursement Coordinator said she had reached out to the facility after the 20-day timeframe to inform them they were out of compliance with PASRR services. The Clinical Reimbursement Coordinator said another IDT meeting was held regarding Resident #1 on 9/16/25 and the NFSS for the mattress was still needed. The Clinical Reimbursement Coordinator said as of today the facility was still out of compliance. During an interview on 11/18/25 at 2:58 p.m. the MDS Coordinator said the facility did not have an NFSS for DME for Resident #1. During an interview on 11/19/25 at 12:45 p.m. the Administrator said he was unable to find a policy regarding PASRR During an interview on 11/19/25 at 1:21 p.m. the MDS Coordinator said she had been in this position since October 2025. The MDS Coordinator said she had not been trained on PASRR yet and the Corporate Nurse was taking care of PASRR right now. During an interview on 11/19/25 at 1:37 p.m. the Corporate Nurse said she had been performing PASRR for the facility for 2-3 Page 1 of 2 675879 675879 11/19/2025 Terrell Healthcare Center 204 W Nash Terrell, TX 75160

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some months. The Corporate Nurse said if a resident had an IDT PASRR meeting on 6/10/25 with a new specialized service of DME then an NFSS should have started the day of the meeting. The Corporate Nurse said a facility had 25-29 days to submit an NFSS and the NFSS was required to be signed by the physician. The Corporate Nurse said an NFSS for Resident #1's specialized mattress was submitted by the facility on 11/19/25. The Corporate Nurse said the NFSS for Resident #1's specialized mattress should have been submitted in June 2025. The Corporate Nurse said the importance of ensuring an NFSS was submitted timely was to ensure a resident received the care and support needed and any specialized service they required and were eligible for. 675879 Page 2 of 2