Health inspection·December 19, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of Resident #1 on 12/19/2023 at 9:50 AM, he was sitting near the ADON office leading into the lobby area. He was sitting in a specialized wheelchair. He was wearing a soft helmet on his head. He made eye contact and did not speak. An attempted interview on 12/19/2023 at 9:52 AM revealed Resident #1 was not interview able. He would turn his head toward the wall when attempting to communicate with him. Review of an email on 12/19/2023 at 2:40 PM, reflected the Rehab Director emailed the MDS Coordinator on 10/5/2022 with subject Resident #1's PASRR (this assessment helps decide if a nursing facility was the best place for a person with a behavioral, intellectual or developmental disability) . The attachment to the email was the completed NFSS (nursing facility specialized services) for Habilitative Therapies form of the information from physical therapy, speech therapy, and occupational therapy. 2, Review of Residents #2 face sheet dated 12/19/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: down syndrome (causes lifelong intellectual disability and developmental delays), muscle wasting and atrophy (thinning of muscle mass), cognitive communication deficit, (difficulty with thinking and how someone uses language), muscle weakness (when full effort does not produce a normal muscle contraction or movement), difficulty with walking, abnormalities of gait and mobility (occurs when the body systems that control the way a person walks do not function in the usual way), ataxic gait (unsteady and uncoordinated way of walking. A person may feel they need to hold onto something as they walk), cerebral palsy (affects movement, muscle tone, balance and posture), dysphagia (difficulty with swallowing food or liquid). (and stiffness of right and left knee (tightness in and around knee joint that can make it hard to move the joint). Review of Resident #2's Quarterly MDS dated , 09/23/2023, reflected Resident #2 had a BIMS score of five indicated his cognition was severely impaired. Resident #1 required assistance with ADLs. He had received physical therapy (restore the normal function of the body), occupational therapy (helps people with physical, emotional, or social problems), and speech therapy (helps people improve their communication skills and help with eating and drinking problems). Review of Resident #2's Comprehensive Care Plan dated, 09/15/2023 reflected Resident #2 had cerebral palsy (affects movement, muscle tone, balance and posture), limited range of motion to knees and ankles. He had impaired cognitive function related to down syndrome (causes lifelong intellectual disability and developmental delays). Resident #2 was assessed to be at risk for falls. He had DD (development disability) and was PASRR positive. Resident #2 had contracture to left elbow. He also required assistance with ADLs. He had a swallowing problem related to dysphagia (difficulty with swallowing food or liquid). Observation on 12/19/2023 at 10:04 AM, Resident #2 was in his room and lying in bed. Resident #2 was smiling and counting how many times he had completed the exercise on each arm. In an interview on 12/19/2023 at 10:06 AM, Resident #2 stated he did arm exercises every day. He stated he was feeling good. He asked, can you come back tomorrow. There is things I need to do today and do not have time for people to visit me today? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675897 If continuation sheet Page 2 of 4 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 675897 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franklin Nursing Home 700 Hearne St Franklin, TX 77856 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Email on 12/19/2023 at 2:48 PM reflected the Rehab Director emailed the MDS Coordinator on 10/5/2022 with subject Resident #2's PASRR. The attachment to the email was the completed NFSS for Habilitative Therapies form of the information from physical therapy, speech therapy, and occupational therapy. Review of Email on 12/19/2023 at 3:10 PM reflected the PASRR Representative (through the state HHSC) sent an email to the MDS Coordinator dated 01/26/2023. A follow-up to a compliance phone call - PASRR information of high importance. The email reflected as discussed on the phone, you (MDS Coordinator) will need to submit a NFSS request form from PASRR Specialized Services (therapies and assessments OT, PT and ST) by 01/31/2023 through the Texas Medicaid and Healthcare Partnership Long Term Portal (the link to this portal was provided in the email). The email also reflected the directions on how to complete a Nursing Facility Specialized Service Form, the new security access to submit the Nursing Facility Specialized form, and a telephone number if there were any questions. Review of Email from the PASRR Representative to the MDS Coordinator and the Administrator on 12/19/2023 at 3:15 PM reflected the email was dated 02/07/2023. A follow up to a compliance phone call PASRR information and avoiding denials. The full email was not provided at time of exit. Review of electronic medical records on the MDS Coordinator Computer reflected Resident #1 and Resident #2 was approved for OT, ST and PT on 02/23/2023. Review of Resident #1's and Resident #2's Physical Therapy, Speech Therapy, and Occupational Therapy on 12/19/2023 at 3:10 PM reflected both men continued their therapy per physician orders during the time period the NFSS was not submitted and the facility was waiting on the approval of therapies for both me. In an interview on 12/19/2023 at 12:15 PM, the MDS Coordinator stated she did not submit Resident #1's or Resident #2's NFSS forms by the due date. She stated she did speak with someone from the PASRR office and explained to the person that she did not have the time to complete the NFSS forms. The MDS Coordinator stated the Rehab Director did email her the NFSS forms in October 2022 on Resident #1 and Resident #2. She stated between October 2022 and the due date of the NFSS on 01/31/2023 was sufficient time to submit the NFSS forms. She stated OT, PT, and ST did fill out the NFSS form correctly when it was emailed to her in October 2022. She stated she could not remember the exact date in October. She stated if therapy had quit seeing Resident #1 and Resident #2 until the services was approved by the PASRR department, there was a possibility that Resident #1 and Resident #2 may have had a decline in their physical condition, range of motion, and cognition. She stated it was her responsibility to submit the NFSS forms. She stated she became busy and did not submit the NFSS forms by the due date of 01/31/2023. In a phone interview on 12/19/2023 at 1:19 PM, the Rehab Director stated she emailed the completed NFSS forms to the MDS Coordinator in October 2022. She stated she did not know the exact date. The Rehab Director stated Resident #1 and Resident #2 never went without therapy according to their physician orders during this time. She stated it was time for their therapy to be approved by the PASRR for Rehabilitation Office. She also stated she remembered talking about therapy and the NFSS in a meeting but she would need to be in the office to recall which meeting and the date of the meeting. She stated she remembered the MDS Coordinator being in the meeting due to discussing renewing the NFSS forms with the PASRR specialized services office. She stated the approval was sometime in February. The Rehab Director stated when anyone was on therapy through PASRR services, the residents never miss any of their therapy if they are waiting on forms to be approved. She stated to look through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675897 If continuation sheet Page 3 of 4 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 675897 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franklin Nursing Home 700 Hearne St Franklin, TX 77856 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)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1's and Resident #2's therapy records during that time period and the records would indicate these two men (Resident #1 and Resident #2) received OT, PT, and ST. In an interview on 12/19/2023 at 1:40 PM, the ADON stated he was not familiar with the process of the NFSS forms. He stated he was aware of PASRR when a resident was admitted to the facility. He also stated if there was a due date for the NFSS to be submitted and the Specialized Service Representative emailed a deadline for the NFSS to be submitted the MDS Coordinator was expected to submit the NFSS by the due date documented in the email from the Specialized Service for PASRR office. The ADON stated he reviewed the therapy documentation during the time period of October 2022 and February 2023. He stated Resident #1 and Resident #2 continued receiving OT, PT, and ST . He also stated there was more than enough time for the MDS Coordinator to submit the NFSS form when the Rehab Director sent her the email in October 2022 (he did not know the exact date) and by the due date of 01/31/2023 documented in the email from the Specialized Service Representative from PASRR to the MDS Coordinator. In an interview with MDS Coordinator on 12/19/2023 at 2:00 PM requested records of the IDT meetings when Resident #1's and Resident #2's therapy was discussed during these meetings. The records were not available at time of exit. In an interview on 12/19/2023 at 3:45 PM, the Administrator stated the NFSS forms were to be completed and submitted to the PASRR Representative before the due date. He stated the MDS Coordinator was responsible for submitting the NFSS and completing the PASRR. He stated there was no reason why the MDS Coordinator did not submit the NFSS form on time. He stated he was not aware prior to today (12/19/2023) that the NFSS forms on Resident #1 and Resident #2 were not submitted. He stated when the second email was sent by the NFSS Specialized Office he informed the MDS Coordinator to submit the NFSS form on time. He did not respond to any other questions of who was responsible to monitor the MDS Coordinator. The facility's policy on PASRR Nursing Facility Specialized Services dated 03/06/2019 reflected the NFSS forms are submitted timely and accurately. Utilize the following resources: 1. HHSC Companion Guide for completing the NFSS forms. 2. HHSC Detailed Item Guide for NFSS forms. 3.TMHP Manual: Long Term Care Guide for PASRR for Nursing Facilities. 4. HHSC Detailed Item Guide for PCSP Forms. The NFSS will be submitted in the electronic site for NFSS within 24 hours of receipt of the Assessment/Service from therapy and will be monitored daily for approval/denial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675897 If continuation sheet Page 4 of 4