Health inspection·December 23, 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 observation, interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident's assessment, care planning, and transition of care for 1 (Resident #1) of 5 residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting .This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.Record review of Resident #1's face sheet dated 12/23/25 revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses[KS1] included- contracture( a permanent shortening or tightening of the muscles, tendons, ligaments or skin, making it hard to fully move the affected body part or joint unspecified joint, cerebral palsy ( a permanent condition from early brain damage that affects movement, balance and posture causing issues like stiff muscle, poor coordination, tremors and can also impact speech, vision), unspecified, anemia (low blood count), unspecified, tachycardia( irregular heart beat that is too fast), unspecified, profound intellectual disabilities, dysphagia, oropharyngeal phase, cognitive communication deficit, hypothyroidism (not making enough hormones causing body metabolism to slow down), unspecified, constipation, unspecified, gastrostomy status ( tube inserted in stomach through a surgical procedure for feeding), muscle weakness (generalized), stiffness of joint, not elsewhere classified, muscle wasting and atrophy, not elsewhere classified, unspecified site, need for assistance with personal care, unspecified protein-calorie malnutrition. Record review of Resident #1's PASRR evaluation dated 01/07/2019 indicated Resident #1 was positive for Intellectual disability. Record review of PCSP dated 08/04/25 indicated there was a recommendation for Resident #1 to receive a prosthetic device. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 meaning severe cognitive impairment. Record review of Resident #1's care plan dated 09/06/25 indicated Resident #1ASRR assessment has identified, DX: profound intellectual disabilities. Specialized services will be provided to maintain the highest level of function.Intervention 08/04/2025: PASRR Annual Meeting conducted at this time. Resident # 1's Diversion Coordinator, Habilitation Coordinator, Physical Therapy, Social Worker and Registered Nurse agreed with the plan. Follow up with local authority's recommendations as indicated by resident current condition. or designee will contact the local authorities to alert them of the resident admission/Readmission Record review of Resident #1's clinical record revealed no evidence of an NFSS form. During [KS2] observation of Resident #1 on 12/23/25 at 10:30AM, Resident #1 was lying was in bed, head to toe assessment done. Resident #1 had upper and lower extremities contracture, not able to respond verbally to any questions or make any eye contact, had Gastrostomy tube and was totally dependent on ADL's[KS3] ( feeding, personal hygiene, incontinent of bowel/bladder and transfer). During an interview on 12/23/25 at 12:05PM, the social worker (SW)[KS4] , said he was not responsible for PCSP recommendations. ,During an Page 1 of 2 675901 675901 12/23/2025 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 12/23/25 at 12:12PM, the MDS coordinator ALVN, said she was not aware of Resident #1's PCSP recommendation prosthetic device and was not sent to NFSS[KS5] . She said failure to submit an NFSS as required may prevent residents from receiving services needed for their wellbeing. During an interview on 12/23/25 at 12:43PM, Physical Therapy (PT)[KS6] , said he did not recommend any devices for Resident #1 when he attended the PASRR meeting on 8/4/25. He said Resident #1 was receiving speech therapy, physical therapy and occupational therapy for 30 minutes each 3 times a day. He said he would be careful to review PCSP recommendations with PASRR positive residents[KS7] . During an interview on 12/23/25 at 3:57PM, the facility Administrator said MDS Coordinator A[KS8] was responsible for doing PASRR. She said Resident #1's PCSP was an honest mistake[KS9] . She had called and sent an email to the PASRR local office but there was no response, and she would follow up after the holidays. She said failure to submit NFSS as required may prevent residents from receiving services needed for their wellbeing. During an interview with RN on 12/23/25 at 4:30PM, he said Resident #1's NFSS was not submitted because at the time of the meeting, he was not aware of the recommendation of a prosthetic device for Resident #1. He said the local PASRR office new workers checked the wrong recommendation. He said failure to submit an NFSS as required may prevent residents from receiving services needed for their wellbeing. Record review of facility Policy on PASRR dated 07/2007 reflected: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State.PURPOSE: This facility shall not admit on or after January 1, 1989 any new residents with: I. Mental illness as defined in paragraph (m)(2)(i), 42 CFR 483.20 of the SOM unless the State mental health authority has determined , based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission: A. That because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility and;B. If the individual requires such level of services, whether the individual requires specialized services for mental retardation[KS10] . 2. Mental retardation, as defined in paragraph (m)(2)(ii), 42 CFR 483.20 of the SOM unless the State mental retardation or developmental disability authority has determined prior to admission: A. That because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility, and;B. If the individual requires such level of services, whether the individual requires specialized services for mental retardation. PROCEDURES: 1. A PASRR shall be completed on every resident upon admission. 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR. 3. Social Services shall contact the appropriate State Agency for referral of specialized care and services the residents may require. Cambridge Health & Rehab (5333)Exit: 12/23/25 675901 Page 2 of 2