Inspection·April 13, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the ST Evaluation and Plan of Treatment dated [DATE] indicated Resident #1 was evaluated for ST services. The ST Evaluation and Plan of Treatment indicated Resident #1's plan of treatment included ST services 1 time a week for 30 days from [DATE] through [DATE]. Record review on Service Authorizations dated [DATE] through [DATE] made to PASRR indicated Resident #1 did not have an authorization submitted for ST services. During an interview on [DATE] at 9:09 a.m. the DOR said she started at the facility on [DATE]. The DOR said she was responsible for ensuring PASRR positive residents received the habilitative services in their service plan. The DOR said the previous speech therapist had evaluated Resident #1 and determined he did not need ST services. The DOR said Resident #1 had a PASRR meeting scheduled for [DATE] and she planned to revisit him receiving ST services. The DOR said she felt if a resident qualified for PASRR services they should be receiving the services if they did not refuse. During an interview on [DATE] at 9:45 a.m. the DOR said the ST evaluation for Resident #1 indicated he was to receive ST services. The DOR said after the evaluation was completed it should have been sent for authorization through PASRR. The DOR said there had not been a PASRR authorization submitted by the facility for Resident #1 to receive ST services. The DOR said without the submission and authorization Resident #1 would not have received ST services. The DOR said when she discharged Resident #1 from ST services on [DATE] (the date she started at the facility) his certification period had expired and she planned on getting a new referral for Resident #1 at his next PASRR meeting scheduled for [DATE]. During an interview on [DATE] at 12:25 the PASRR Service Coordinator said the facility had 20 days after a recommendation/referral for a resident was made to get the evaluation and submit for authorization. The PASRR Service Coordinator said if an authorization submission was not completed the resident would not be receiving the recommended service(s) under PASRR. During an interview on [DATE] at 1:37 p.m. the MDS Nurse said she was the one in charge of taking care of PASRR for the past 2 years. The MDS Nurse said once recommendations were made from PASRR therapy was supposed to evaluate the resident as soon as they received the recommendation/referral and then submit for authorization. The MDS Nurse said she was unaware until the DOR told her on [DATE] that Resident #1's ST evaluation had not been submitted for authorization. The MDS Nurse said the previous DOR had told her she submitted for authorization on all therapy disciplines for Resident #1. The MDS Nurse said she was under the impression the previous speech therapist had picked Resident #1 up on her caseload pending authorization. The MDS Nurse said she was unaware until being informed by the DOR on [DATE] that Resident #1 had not been receiving ST. The MDS Nurse said not receiving recommended/referred habilitative services could cause a decline in a resident's baseline functioning abilities. During an interview on [DATE] at 1:45 the MDS Nurse said the DOR was trying to find a policy on Rehabilitation/Therapy services. The policy was never provided to the Surveyor. Record review of the facility's Pre-admission Screening Resident Review (PASRR) dated [DATE] indicated, .Once the interdisciplinary team (IDT) makes a determination about specialized care, the facility will: 1. Include all specialized services and support activities in the residents comprehensive care plan, 2. The facility will initiate the request for specialized services within 20 business days of the IDT meeting, implement Specialized Services therapy within 3 business days after receiving approval .There are 3 types of Specialized Services that may be provided, the facility is responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675981 If continuation sheet Page 2 of 3 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 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for the coordination of these services .1.Nursing Facility Specialized Services a. Physical, Speech, or Occupational Therapy .To be eligible for reimbursement, the Nursing Facility must request and receive authorization from the Health and Human Services Commission (HHSC) prior to purchasing or delivering specialized service. The facility requests prior authorization for specialized services for individuals with Intellectual Disabilities/Intellectual Developmental Disabilities by submitting a request through the online portal Event ID: Facility ID: 675981 If continuation sheet Page 3 of 3