Health inspection·March 25, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impairment. He had unclear speech and was usually understood and usually understood verbal communication. He required substantial or maximal assistance for most activities of daily living and used a wheelchair for mobility. He was considered by the state level II PASRR process to have serious mental illness and intellectual disability. During an observation on 03/25/2025 at 10:30 a.m., Resident #1 was sitting in his standard wheelchair in his room. Resident #1 reported that he was pleased with care provided by the facility and used his standard wheelchair to move about the facility without difficulty. Resident #1 acknowledged that he is to receive a custom wheelchair, but it has not been delivered. During an interview on 3/24/2025 at 4:05 p.m., the Clinical Reimbursement Coordinator said PASRR requirements mandate that the facility complete an accurate request for NF specialized services recommended (CMWC) and agreed upon at the IDT meeting into the online portal within 20 business days and DME or a CMWC must be ordered within 5 business days after receiving notification of the approval through the LTC Online Portal. She said Resident #1 refused a CMWC during quarterly meetings up until 01/16/2025 and even though the facility physical therapist did not recommend a CMWC for Resident #1, the Habilitation Coordinator explained to the IDT that PASRR's decision regarding the CMWC overrules the facility therapy's determination regarding the CMWC and the facility initiated the request for NF specialized services in the LTC Online Portal. She said she completed the facility section of the request and forwarded it to the DME company for them to complete their section and they entered the information into the LTC Online Portal. She said the quarterly IDT meeting for Resident #1 was on 01/16/2025, and she entered the information into the LTC Online Portal on 01/30/2025. She said on 02/05/2025 she received multiple alerts from the LTC Online Portal which identified the CMWC request had errors or sections that needed to be reviewed and completed. She said that she reviewed the document on the Online Portal on 02/05/2025 and made the requested corrections and resubmitted the CMWC request. She said the CMWC request was approved on 02/12/2025. She was unsure when she notified the DME company Resident #1's CMWC request was approved. During an interview on 03/25/2025 at 3:15 p.m., the office manager with the DME company said they received the approval for Resident #1's CMWC on 02/24/2025 via email from the facility Clinical Reimbursement Coordinator with a screen shot of the LTC Online Portal attachment indicating that the CMWC request was approved on 2/12/2025. She said they ordered the Customized Wheelchair for Resident #1 on 02/24/2025 and the equipment should be delivered to the facility 3/26/2025. During an interview on 3/25/2025 at 5:30 p.m., the DON said the Clinical Reimbursement Coordinator was responsible for coordinating all things PASRR related. She said she was familiar with the PASRR process and what documents were required to be completed but not the timelines for completion. She said she was aware that Resident #1 was PASRR positive and evaluated for a CMWC and was waiting for the delivery from the DME company. She said during the quarterly IDT meeting on 01/16/2025 the Habilitation Coordinator explained to the IDT that PASRR's decision regarding the CMWC overrules the facility therapist's determination regarding the CMWC and the CMWC process was initiated at that time. She said a possible negative outcome of not meeting the PASRR timeframes for completing the CMWC request and ordering the CMWC could be residents not receiving services as approved through PASRR. During an interview on 3/25/2025 at 6:10 p.m., the Administrator said the Clinical Reimbursement Coordinator was responsible for any updates for PASRR and submitting the specialized services/DME request on the LTC Online Portal. He said he was aware that Resident #1 was approved for a CMWC and was waiting for the equipment to be delivered. The Administrator said he received calls from PASRR staff and provides the requested documents. He said residents might not get the services/DME that PASRR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676094 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 676094 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Orange 4201 Fm 105 Orange, TX 77630 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 provided if requests were not submitted in the required timeframes. He said he expected the facility staff to follow the PASRR policy and meet the required timelines for submitting the request for specialized services or DME and notifying the DME company when facility notified of the DME approval. Record review of an undated facility policy titled PASRR indicated . Policy: the purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately. Procedure: 1. PASRRs are obtained from referring entity by the admissions department. 2. PL1s are put into LTC online portal by the facility CRC within 72 hours of resident admitting to facility. The completed PL1 must also be uploaded into the resident's EMR. 3. Communicate with LIDDA/LMHA to ensure all active positive PL1s have a completed PE and upload the PE into the resident's EMR. 4. Review recommended specialized services on the PE once the PE is submitted. 5. When discharging a resident to another NF, the facility is responsible for completing PASRR for the NF. 6. Follow Texas PASRR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. Event ID: Facility ID: 676094 If continuation sheet Page 3 of 3