Health inspection·October 9, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few member of therapy to care plan meetings. Therapy services as ordered. Resident #1 had an ADL self-care performance deficit. The interventions were: Provide supportive care, Ensure hip abductor while in chair. Provide assistance with mobility as needed. Resident #1 was high risk for falls. She had multiple sclerosis affecting lower extremities and she had paraplegia. Review of Resident #1's PASRR Comprehensive Service Plan Form dated 04/05/2023, reflected section Nursing Facility Specialized Services a durable medical equipment was listed under the PASRR Evaluation service. The orthotic device ( to straighten or correct problems in a human's muscle or skeletal system) was the durable medical equipment was recommended in the meeting. Review of Email from PASRR Representative to the MDS Coordinator and the Administrator dated 06/28/2023 reflected from the phone conversation, you will need to submit a Nursing Facility Specialized Services request form for PASRR specialized services for DME for orthotic device by 06/30/2023. The email reflected directions on how to complete a Nursing Facility Specialized Services form, the new security access to submit the Nursing Facility Specialized form, and a detailed item-by-item guide for completing the authorization request for PASRR Nursing Facility Specialized Service form (PDF). In the email there were links to all these instructions. Review of Resident #1's PASRR Nursing Facility Specialized Services Request Form dated 06/30/2023 submitted to PASRR for durable medical equipment approval. The equipment was (orthotic device to straighten or correct problems in a human's muscle or skeletal system). The PASRR Nursing Facility Specialized Services form dated 06/30/2023 returned to the facility with a status of denied. Review of Resident #1' PASRR Comprehensive Service Plan Form dated 07/05/2023 reflected section Nursing Facility Specialized Services a durable medical equipment was listed under the PASRR Evaluation service. The orthotic device was received. Review of Email from PASRR Representative to Administrator dated 08/14/2023 reflected this email was to summarize our phone conversation regarding your facility's non-compliance with the requirements outlined in the Texas Administrative Code, Chapter 19, Subchapter BB, section 19.2704 (i)(7)(A), which states your facility must initiate nursing facility specialized services within 20 business days after the date that the services are agreed to in the IDT meeting for the resident we spoke about. As discussed on the phone, you will need to submit a NFSS (Nursing Facility Specialized) request form for PASRR Specialized Services ( Therapies and Assessments OT and PT) by 08/16/2023 through the Texas Medicaid and Healthcare Partnership Long Term Care Portal. The link of the portal was provided on the email. Your facility required to check the status of the requests daily to ensure they are approved. Prompt attention should be given to the request if it had a pending denial status once it was submitted. This was a time sensitive status and can result in system generated denial if not followed up by date noted on the reviewer in the request. If your facility uses a third party vendor, you will need to contact the vendor for assistance. The email reflected directions on how to complete a Nursing Facility Specialized Services form, the new security access to submit the Nursing Facility Specialized form, and a detailed item-by-item guide for completing the authorization request for PASRR Nursing Facility Specialized Service form (PDF). In the email there were links to all these instructions. In an interview/observation on 10/04/2023 at 10:30 AM with Resident #1 stated she did have a new thing to help her sit straight. She stated yes, it was by her hip and her she had one, but it was getting old, and she wanted a new one. Resident #1 stated the therapy got it for her and she was happy with it. Resident #1 was observed having the orthotic device and it looked new. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 2 of 4 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 In an interview on 10/09/2023 at 9:30 AM PTA Rehabilitation Coordinator stated, He stated Resident #1 was admitted to facility in March of 2023. He stated he did not know the exact date. He stated Resident #1 was admitted with a hip abductor orthotic device. He stated during a meeting with PASRR representative Resident #1 mentioned she wanted a new one for her side. He stated they asked her if she was referring to the hip device she was wearing, and Resident #1 stated yes. He stated the PASSR representative stated they could get the device through the Texas Medicaid and Healthcare Program. PTA stated he found out few days before the date the Forms was to be filled out was required to be submitted on 06/30/2023. He stated he had called two different suppliers to order the orthotic device and the suppliers refused to sign the receipts and fill out the proper paperwork. He stated he did submit the NFSS (Nursing Facility Specialized) request form on 06/30/2023 and it was returned on 07/03/2023 stating it was denied. He stated he had contacted different people with the PASRR to ask questions concerning the suppliers refusing to sign receipt or any forms. He stated he did not receive any answers and he stated he did not document any conversations he had with the suppliers. PTA also stated he ordered the device for Resident #1 and the facility paid for it. He stated Resident #1 had the orthotic hip protector device the entire time she was admitted to the facility in March 2023. He stated the new orthotic hip protector device was delivered to the facility on first week of July. He stated he did not fill out a new NFSS (Nursing Facility Specialized) due to it would be denied again. He stated he could not receive any instructions on what to do if a supplier kept denying to fill out the appropriate paperwork and denied to sign any receipts. He stated he did not recall who he talked to from the suppliers. PTA also stated he did not feel it was necessary to fill out the forms again due to resident already had a new device and he did not have the appropriate receipts to submit, and the request would continue to be denied. In an interview on 10/09/2023 at 10:02 AM the MDS Coordinator stated she did receive an email from the PASRR Representative on 06/28/2023. She stated when she received the email, she printed it and gave the printed copy to the Director of Rehabilitation (PTA). She stated the PASRR Representative had call her and explained she was emailing the NFSS (Nursing Facility Specialized) request form. She stated she reported the information from the phone call with the PASRR Representative with the Administrator on 06/28/2023. She stated she did not have any other involvement with the PASRR process. MDS Coordinator did state she knew that Resident #1 did receive a new orthotic hip protector device first week of July. She stated Resident #1 was admitted with this device in March 2023. She stated she did not know the exact date she was admitted . Resident #1 had been in the hospital and was readmitted to the facility March 5, 2023. In an interview on 10/09/2023 at 10:42 AM the Social Worker stated during a care plan meeting it was discussed Resident #1 wanted a new device for her hip. She stated Resident #1 already had the device but wanted a newer one. She stated Resident #1 was admitted with device for her hip and she had observed her wearing it every time she had contact with Resident #1. In an interview on 10/092023 at 11:10 AM the Administrator stated he expected all information discussed in the care plan meetings, especially if there were any decisions made about specialized devices be documented in the IDT meeting notes in the electronic medical records. He stated when he reviewed the email sent by the PASRR Representative on 06/28/2023 he was trying to understand the process PASRR was wanting the facility to follow for Resident #1 to receive the device she needed. He stated he directed the PTA to order the device and the facility would pay for it. He stated the second email got his attention. The Administrator stated when the device for Resident #1 was denied by PASRR he stated the PTA was expected to submit another NFSS (Nursing Facility Specialized) request form by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 3 of 4 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 676180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 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 the deadline of 08/16/2023. He stated he was not very concern about it due to the facility bought her another orthotic hip protector device due to Resident #1 requested a new one. He stated she had an orthotic hip protector device since she was admitted according to the PTA and MDS Coordinator. He stated from his understanding Resident #1 already had the orthotic device for her hip. He stated if he knew the importance of re submitting the request form to the PASRR office he would made sure it was submitted even if they knew it would be denied again. Requested invoices of the orthotic hip protector device on 10/9/2023 from the Administrator and the PTA/ Rehabilitation Coordinator. The invoices were not provided upon time of exit. Requested on 10/09/2023 from the Administrator and the MDS Coordinator related to the resident being readmitted in March 2023 with the orthotic hip protector device and this information was not provided upon time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676180 If continuation sheet Page 4 of 4