Health inspection·April 11, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews and record reviews a facility must coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes, Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 5 of 5 (Resident #1, #2, #3, #4, #5.) resident with PASRR recommendations in that: Resident #1 NFSS for therapy services was not submitted timely. Resident #2 NFSS for therapy services was not submitted timely. Resident #3 NFSS for therapy services was not submitted timely. Resident #4 NFSS for therapy services was not submitted timely. Resident #5 NFSS for therapy services was not submitted timely. The Failures could affect residents who require PASRR services and could result in residents not receiving the PASSR recommended specialized services. The findings included: Record review of Resident #1's admission record dated 4/10/2024 revealed the resident was admitted on [DATE], re-admitted on [DATE] with diagnoses of Dementia, moderate intellectual disabilities (condition that affects general mental abilities and adaptive functioning), muscle wasting (both legs), dysphagia (difficulty in swallowing food or liquid), unsteadiness on feet. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's BIMS was 3 which indicated severely cognitively impaired. Record review of Resident #1's Care plan dated 4/10/2024 revealed Resident #1 had a positive PASRR status on 3/31/2023 related to an intellectual disability/MR (mental retardation) after The LIDDA finished their investigation into my diagnoses. Interventions: Habilitative OT/ST and customized wheelchair has been approved for 6 months at a time. 7/17/2023 Resident #1's Guardian agreed to continue OT/St services for another 6 months. Page 1 of 5 676116 676116 04/11/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's P1 (PASARR 1) dated 3/31/2023 revealed Resident #1 had an intellectual disability, indicated as yes. Record review of Evaluation revealed a response of Yes for Intellectual Disability, Developmental Disability. Record review of Resident #1's PASSR Comprehensive Service Plan (PCSP) dated 1/10/2024 revealed Resident #1 was recommended OT, PT, and ST. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #1 has not received a Medicaid service as a result of the following: 1. Nursing Facility did not submit PASRR NF Specialized Service Assessments within HHS's required timeframe - 1/30/2024. Resident #2 Record review of Resident #2's admission record dated 4/10/2024 was admitted on [DATE], re-admitted on [DATE] with diagnoses of severe intellectual disabilities (condition that affects general mental abilities and adaptive functioning) and cerebral palsy (neurological disorder that affects movement and muscle tone). Record review of Resident #2's annual MDS dated [DATE] revealed Resident #2's BIMS was 0 which indicated severely cognitively impaired. Record review of Resident #2's Care plan dated 4/10/2024 revealed Resident #2 had a positive PASRR status on 3/22/2023 related to cerebral palsy and intellectual disabilities. Interventions: .getting up in wheel chaire once facility receives his specialized wheelchair . Record review of Resident #2's P1 (PASRR 1) dated 2/27/2023 revealed Resident #2 had an intellectual disability, indicated as yes. Record review of Evaluation revealed a response of Yes for Intellectual Disability, Developmental Disability. Record review of Resident #2's PASSR Comprehensive Service Plan (PCSP) dated 2/06/2024 revealed Resident #2 was recommended OT, PT, and ST. Meeting was held on 2/06/2024. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #2 has not received a Customized Manual Wheelchair assessment to assist with safe positioning and mobility after a 2/6/2024 PASRR update meeting. Nursing Facility did not submit the NF Specialized Customized Manual Wheelchair assessment within the required timeframe. Resident #3 Record review of Resident #3's admission record dated 4/11/2024 was admitted on [DATE], re-admitted on [DATE] with abnormalities of gait and mobility, cognitive communication deficit, psychosis not due to a substance, schizoaffective disorder-bipolar type (serious mental illness characterized by extreme mood swings). Record review of Resident #3's annual MDS dated [DATE] revealed Resident #3's BIMS was 12 which indicated moderately cognitively impaired. Record review of Resident #3's Care plan dated 4/10/2024 revealed Resident #3 had a positive PASRR status on 9/30/2022 related to intellectual disabilities/mental illness for schizophrenia/MDD. 676116 Page 2 of 5 676116 04/11/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interventions: OT specialized services approved for 6 months at a time on 1/25/2023. Evaluate for habilitative services and or durable medical equipment to maintain current level of function. ST specialized services approved for 6 months at a time on 4/27/2023. Record review of Resident #3's P1 (PASARR 1) dated 9/13/2022 revealed Resident #3 had an intellectual disability/developmental disability and mental illness, indicated as yes. Record review of Resident #3's PASSR Comprehensive Service Plan (PCSP) dated 2/6/2024 revealed Resident #3 was recommended OT, ST, and DME. Meeting was held on 2/06/2024. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #3 has not received NF Specialized PT and OT assessments in support of maintaining strength and ADL's after the SPT agreed to needed services at a 2/06/2024 PASRR update meeting. NF did not submit NF Specialized therapy assessments within the required timeframe. Resident #4 Record review of Resident #4's admission record dated 4/11/2024 was admitted on [DATE], re-admitted on [DATE] with diagnosis of legal blindness, Parkinson's disease (chronic and progressive movement disorder), muscle wasting, and difficulty walking. Record review of Resident #4's quarterly MDS dated [DATE] revealed Resident #4's BIMS was 14 which indicated cognitively intact. Record review of Resident #4's Care plan dated 4/10/2024 revealed Resident #4 had a positive PASRR status on 5/19/2021 related to developmental disability - legal blindness. Interventions: .evaluate for habilitative services and or durable medical equipment to maintain current level of function. Record review of Resident #4's P1 (PASRR 1) dated 9/15/2023 revealed Resident #4 had a developmental disability indicated yes. Record review of Resident #4's PASSR Comprehensive Service Plan (PCSP) dated 9/15/2022 revealed Resident #4 was recommended return to the community. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #4 has not received NF Specialized PT, OT, and a Customized Manual Wheelchair assessments in support of maintaining strength, ADL's, and mobility after the SPT agreed to needed services at a 1/10/2024 PASRR update meeting. NF did not submit NF Specialized therapy assessments within the required timeframe following the meeting. Resident #5 Record review of Resident #5's admission record dated 4/11/2024 was admitted on [DATE] with diagnosis of quadriplegic cerebral palsy (severe form of cerebral palsy that affects all four limbs, the trunk, and the face), muscle weakness, and difficulty walking. Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5's BIMS was 14 which indicated cognitively intact. 676116 Page 3 of 5 676116 04/11/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #5's Care plan dated 4/11/2024 revealed Resident #5 had a positive PASRR status on 3/10/2021 related to spastic quadriplegia cerebral palsy. Interventions: 6/15/2023 .agreed to continue habilitation coordination, specialized habilitative PT services. Record review of Resident #5's P1 (PASRR 1) dated 9/15/2023 revealed Resident #5 had a developmental disability indicated yes. Record review of Resident #5's PASSR Comprehensive Service Plan (PCSP) dated 2/06/2024 revealed Resident #5 was recommended OT, PT, DME. Meeting was held on 2/6/2024. Record review of complaint intake #491508 dated 3/20/2024 revealed Resident #5 has not received NF Specialized PT, OT, and ST assessments to assist with receiving therapy authorization approval in support of maintaining strength and ADL's after SPT agreed to needed services at a 2/2/2024 PASRR update meeting. The NFSS was not submitted within the required timeframe. Interview on 4/10/2024 at 11:25 AM with the MDS Reg. Coord. said the Rehab. Director was responsible for submitting the NFSS forms. MDS Reg. Coord. said the previous Rehab. Dir. resigned in February 2024. She said there was not a replacement until the middle of March. MDS Reg. Coord. said in January she tried to help but there was a delay in doctor signatures which in turn delayed the NFSS submissions. She said by not submitting the NFSS form it would delay approval of specialized services. MDS Reg. Coord. said delay in services could affect residents maintaining their current strength or abilities. MDS Reg. Coord. said the NFSS forms were not submitted in 1/2024 and 2/2024 to PASRR. Interview on 4/11/2024 at 8:45 AM with Resident #1 was attempted in the hospital. Resident #1 did not answer if he had OT, PT or ST after questions were asked. Interview on 4/11/2024 at 11:15AM, Resident #5 said she had not been to therapy in months and started yesterday. Interview on 4/11/2024 at 11:35 AM, Interim Rehab. Dir. said the facility had staff changes in the rehabilitation therapy department. She said she took over the Rehabilitation Director duties temporarily until a new director was hired. The Interim Rehab. Dir. said the previous Rehab. Director was responsible for submitting the NFSS forms. The Interim Rehab. Dir. said the NFSS forms for specialized services were not submitted after the PASRR meetings held in January and February of 2024. She said the facility did not have a full time Rehab. Dir. and the facility failed to submit the NFSS to the LIDDA. She said services for PASRR residents would have been delayed because the NFSS was not submitted. She said she reviewed the therapy notes for Resident's #1, #2, #3, #4, and #5 and the note's revealed evaluations were completed, but there was no therapy (OT, PT, ST, or DME) sessions completed. She said the services were not started because the NFSS form was not submitted to PASRR (for Residents #1, #2, #3, #4,#5) after the IDT meetings and the process (assessment, submission of NFSS to start services) had to be started over again. Interview on 4/11/2024 at 12:00 PM with Resident #2 was attempted. Resident #2 did not respond to questions asked related to OT, PT, ST. Interview on 4/11/2024 at 12:10 PM, Resident #3 said she wanted to go to therapy to exercise. She said she did not remember if she attended therapy. Interview on 4/11/2024 at 12:30 PM, Resident #4 said he had not been to therapy in over a month and 676116 Page 4 of 5 676116 04/11/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a half. He said he wanted to be in therapy to help with mobility and help as much as he could with his Parkinson's diagnosis. Interview on 4/11/2024 at 1:39 PM, the ADM said the Rehab. Dir. was responsible for submitting the NFSS forms for PASRR services. ADM said the previous Rehab. Dir. resigned three months ago and there was a lapse in a facility staff completing the NFSS forms and submitting them. ADM said the risk would be a delay in specialized services. ADM said the delay in services could affect the residents ability to obtain or maintain skills. NFSS submissions for 1/2024-3/2024 for Residents #1, #2, #3, #4, #5 were requested on 4/11/2023 from Administrator and Interim Rehab. Dir. and were not received before exit. Record review of facility policy Resident Assessment - PASRR dated 11/2023, revealed the following in part: The purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately. 6. Follow Texas PASSR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. authorization request for PASRR Nursing Facility Specialized Services (NFSS) dated November 2023 revealed the following part: The NF submitters must submit the authorization request for a service through the NFSS form no more than 30 days after the date the assessment for the service was completed by the therapist. 676116 Page 5 of 5