Health inspection·November 3, 2023

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, interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for one (Resident #1) of one resident reviewed for PASRR services. The facility failed to order a standing board for Resident #1 based on PASRR assessment for specialized services. This failure could place residents at risk of not receiving specialized PASRR services which could contribute to a decline in quality of life, physical, mental, and psychosocial well-being . Findings include: Record review of Resident #1's face sheet, dated 11/03/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizoaffective disorder, depressive type, unspecified intellectual disabilities, and cognitive communication deficit. Record review of Resident #1's care plan, revised 8/22/23, reflected he was evaluated for PASRR for services for a standing board service for DD (Muscle wasting and atrophy). Interventions included: Obtain a soft padded standing board specialized equipment recommended by Physical therapy, to help resident stand longer with minimal pain against his lower legs against the standing board. Record review of Resident #1's annual MDS assessment, dated 9/10/23, reflected Resident #1 was wheelchair dependent. He could communicate some words or could finish thoughts if prompted or given time in making daily decisions. Resident #1 required partial/moderate assistance - helper did less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort assistance with ADL care. He was considered by the state PASRR evaluation. Record review of Resident #1's service plan with IDT with the Rehabilitation Director, Social Worker, MDS Coordinator, LAR, and Speech/Language/Cognitive therapies was held on 6/01/23 reflected an outcome of meeting was skilled service: To prevent decline in function, improve attention/concentration, and enhance cognitive skills to enhance residents' quality of life by improving ability to participate in functional activities of choice and a new electric wheelchair with a reclining high back. Record review of Resident #1's IDT meeting with LAR on 8/13/23 reflected a soft standing board was recommended by Director of Rehabilitation (DOR) for Resident #1 to achieve a better outcome in his standing during therapies by using a soft padded standing board. 73 days after the IDT meeting and Page 1 of 4 675930 675930 11/03/2023 Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014

F 0644 PASRR approval, Resident #1 had not received the soft standing board paid by PASRR (MCD). Level of Harm - Minimal harm or potential for actual harm In an observation and interview on 11/02/23 at 11:50 a.m. revealed Resident #1 was in an electric wheelchair going to the gym. He said he did not know if he got the standing board. He revealed he liked to go to the gym. No standing board was observed. Residents Affected - Few Interview with the DOR on 11/02/23 at 11:55 AM, revealed the PASRR assessment was done when a change or a decline was identified. He reported he suggested a personal soft standing board and was awaiting the PASRR advocate to get back to him. On 09/2023 he sent an email to the MDS Coordinator (that over saw the PASRR services) but had not gotten a response from her, so no standing board was ordered. He reported because MDS Coordinator had retired and 3 other staff were filled that role of the MDS Coordinator, she may not have seen his emails to follow up. He reported he was unsure who was responsible for ordering equipment but stated he would call, if he was given a response from the PASRR advocate, the company the facility used to do custom measurements for specialized equipment, to come out to take the measurements for Resident #1's soft standing board. The DOR revealed the delay caused the resident delay in receiving specialized service . Interview with MDS Coordinator on11/02/23 at 12:28 PM revealed she was retired and only came into the office once a week until the facility could fully hire a new MDS Coordinator. She revealed when she was not in the office someone from the cooperate office covered once a month and on other times, staff from business development covered that role. She reported she would make sure the DOR obtained the standing board for Resident # 1. She stated the delay caused the resident a delay in receiving PASRR service . Interview with the ADM on 11/02/23 at 5:24 PM revealed she was not aware Resident #1 needed a standing board. She reported the MDS Coordinator screeded the residents for PASRR until she retired at the end of September beginning of October 2023.She revealed a new person was starting on Monday, 11/06/23, in the role of MDS Coordinator. She said in the meantime, 3 staff members were overseeing the PASRR. She said PASRR assessments were done when a change or a decline was identified. The ADM revealed her expectation was to follow through with PASRR recommendations and/or any other assessed needs. The ADM revealed any type of risk could come from a delay in services such immobility, mobility could not improve, risk of injury by not having equipment, and poor progression. She revealed the PASRR process was to screen the resident, obtain a recommendation if applicable, set up a meeting with PASRR advocate, notify via phone call, then the company would come in to take measurements for specialized equipment and/ or wheelchairs, and then the paperwork would be sent to the facility for an order to be placed . Record review of the facility's, undated, policy, PASRR Clinical policy, reflected, .The MDS/PPS Nurse/DON and/or designee will initiate delivery of specialized services within 30 days of the date SS added to the plan 675930 Page 2 of 4 675930 11/03/2023 Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure specialized services or specialized rehabilitative services the nursing facility was provided as a result of PASARR recommendations for one (Resident #1) of one resident reviewed for PASRR. The facility failed to order a standing board for Resident #1 based on PASRR assessment for specialized services as stated in the care plan. This failure could affect residents by preventing them from receiving specialized services as care-planned which could contribute to a decline in quality of life, physical, mental, and psychosocial well-being . Findings include: Record review of Resident #1's face sheet, dated 11/03/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizoaffective disorder, depressive type, unspecified intellectual disabilities, and cognitive communication deficit. Record review of Resident #1's care plan, revised 8/22/23, reflected he was evaluated for PASRR for services for a standing board service for DD (Muscle wasting and atrophy). Interventions included: Obtain a soft padded standing board specialized equipment recommended by Physical therapy, to help resident stand longer with minimal pain against his lower legs against the standing board. Record review of Resident #1's annual MDS assessment, dated 9/10/23, reflected Resident #1 was wheelchair dependent. He could communicate some words or could finish thoughts if prompted or given time in making daily decisions. Resident #1 required partial/moderate assistance - helper did less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort assistance with ADL care. He was considered by the state PASRR evaluation. Record review of Resident #1's service plan with IDT with the Rehabilitation Director, Social Worker, MDS Coordinator, LAR, and Speech/Language/Cognitive therapies was held on 6/01/23 reflected an outcome of meeting was skilled service: To prevent decline in function, improve attention/concentration, and enhance cognitive skills to enhance residents' quality of life by improving ability to participate in functional activities of choice and a new electric wheelchair with a reclining high back. Record review of Resident #1's IDT meeting with LAR on 8/13/23 reflected a soft standing board was recommended by Director of Rehabilitation (DOR) for Resident #1 to achieve a better outcome in his standing during therapies by using a soft padded standing board. 73 days after the IDT meeting and PASRR approval, Resident #1 had not received the soft standing board paid by PASRR (MCD). In an observation and interview on 11/02/23 at 11:50 a.m. revealed Resident #1 was in an electric wheelchair going to the gym. He said he did not know if he got the standing board. He revealed he liked to go to the gym. No standing board was observed. 675930 Page 3 of 4 675930 11/03/2023 Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the DOR on 11/02/23 at 11:55 AM, revealed the PASRR assessment was done when a change or a decline was identified. He reported he suggested a personal soft standing board and was awaiting the PASRR advocate to get back to him. On 09/2023 he sent an email to the MDS Coordinator (that over saw the PASRR services) but had not gotten a response from her, so no standing board was ordered. He reported because MDS Coordinator had retired and 3 other staff were filled that role of the MDS Coordinator, she may not have seen his emails to follow up. He reported he was unsure who was responsible for ordering equipment but stated he would call, if he was given a response from the PASRR advocate, the company the facility used to do custom measurements for specialized equipment, to come out to take the measurements for Resident #1's soft standing board. The DOR revealed the delay caused the resident delay in receiving specialized service . Interview with MDS Coordinator on11/02/23 at 12:28 PM revealed she was retired and only came into the office once a week until the facility could fully hire a new MDS Coordinator. She revealed when she was not in the office someone from the cooperate office covered once a month and on other times, staff from business development covered that role. She reported she would make sure the DOR obtained the standing board for Resident # 1. She stated the delay caused the resident a delay in receiving PASRR service . Interview with the ADM on 11/02/23 at 5:24 PM revealed she was not aware Resident #1 needed a standing board. She reported the MDS Coordinator screeded the residents for PASRR until she retired at the end of September beginning of October 2023.She revealed a new person was starting on Monday, 11/06/23, in the role of MDS Coordinator. She said in the meantime, 3 staff members were overseeing the PASRR. She said PASRR assessments were done when a change or a decline was identified. The ADM revealed her expectation was to follow through with PASRR recommendations and/or any other assessed needs. The ADM revealed any type of risk could come from a delay in services such immobility, mobility could not improve, risk of injury by not having equipment, and poor progression. She revealed the PASRR process was to screen the resident, obtain a recommendation if applicable, set up a meeting with PASRR advocate, notify via phone call, then the company would come in to take measurements for specialized equipment and/ or wheelchairs, and then the paperwork would be sent to the facility for an order to be placed . Record review of the facility's, undated, policy, PASRR Clinical policy, reflected, .The MDS/PPS Nurse/DON and/or designee will initiate delivery of specialized services within 30 days of the date SS added to the plan 675930 Page 4 of 4