Health inspection·June 29, 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 interview and record review the facility failed to coordinate an assessment with Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort and for 1 of 1 resident reviewed for PASRR services coordination and assessment. (Resident #1) The facility failed to submit a complete and accurate NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #1's by a specific deadline. This failure could place residents with a positive PASRR evaluation at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #1's undated face sheet indicated Resident #1 was [AGE] years old, admitted on [DATE], with diagnoses including intellectual disabilities, down syndrome, and Alzheimer's. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and required extensive assistance with ADLs of bed mobility, locomotion on unit, locomotion off unit, transfers, dressing, toilet use and personal hygiene. Record review of Resident #1's care plan dated on 12/16/2022 and revised 04/14/2023 indicated Resident #1 had a positive PASRR status assessment that identified needs for specialized services due to intellectual development related condition and specialized services will be provided to maintain the highest level of function. Listed interventions included: Follow up with local authority's recommendations as indicated . Social services/designee to make referrals for additional services as needed . Record review of Resident #1's undated MESAV Inquiry Report provided by the facility indicated Resident #1's Medicaid was effective 12/14/2022. Record review of Resident #1's PCSP form dated 01/05/2023 indicated Resident #1, diagnosed with intellectual disability, had an initial IDT meeting for specialized services review on 01/05/2023. This PCSP form indicated the IDT members recommended Resident #1 receive new services of CMWC. Page 1 of 2 676147 676147 06/29/2023 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's PCSP form dated 04/10/2023 in the section Nursing Facility Specialized Services indicated Resident #1 had a quarterly IDT meeting review on 04/10/2023. This PCSP form indicated the IDT members recommended the CMWC as an ongoing specialized service for Resident #1. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 04/28/2023 at 1:37 p.m. for Resident #1 read, TMHP: This CMWC Assessment Only is approved. Remember, that this Assessment Only will not result in a CMWC for the resident (Resident #1), if that is what is needed. For a CMWC Request, at the NF/Resident tab, at Section C2000 and C2100, please select CMW for both (not CMWC Assessment Only). This will open the Assessment and information can be provided. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 04/28/2023 at 1:26 p.m. for Resident #1 indicated the NFSS form request for CMWC/DME was not submitted within 30 calendar days of the IDT meeting. Record review of PASRR Compliance Call Report for February 2023 spreadsheet for Resident #1's IDD services PASRR Unit indicated the following: *IDT meeting was held on 01/05/2023, *PCSP was created on 01/09/2023, *IDT date plus 30 days was 02/04/2023, *NF contacted 04/27/2023, *Due date for NF to submit NFSS form in LTC portal for CME/CMWC was 05/03/2023. During an interview on 06/23/2023 at 11:51 a.m., the SW said she attended Resident #1's IDT meetings and Resident #1 had not received the CMWC but approval was in the process. During an interview on 06/23/2023 at 12:18 p.m., the DOR said Resident #1 had not received the CMWC but it had been approved and the facility was awaiting delivery from the DME company. She said there was not a known delivery date. During an interview on 06/23/2023 at 12:23 p.m., the MDS/PASRR Nurse said Resident #1 had not received the CMWC. She said she had been in the position approximately four months and the facility did not have TMHP activity history logs prior to April of 2023 and had no evidence the specialized CMWC assessment was submitted. Record review of the facility provided CMS 672 dated 06/22/2023 indicated there were two residents with intellectual and/or developmental disability. Record review of the May 2014 facility policy entitled PASRR Clinical Policy, section Nursing Facility Responsibilities read, .5. The MDS/DON and/or designee will monitor the LTC Online portal daily .13. The MDS/Nurse/DON and/or designee will initiate delivery of specialized services within 30 days of the date specialized services added to plan . 676147 Page 2 of 2