Inspection·July 17, 2024

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 observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 7 (Resident #1) residents reviewed for PASRR. The facility contacted the HHSC PASRR Unit on 5-7-2024 for Resident #1 and no NFSS (Nursing Facility Specialized Services) form was provided to the HHSC PASRR Unit by the required date of 5-10-2024. This failure could affect residents with mental illnesses and placed them at risk of not being assessed to receive needed services. Findings included: Record review of Resident #1's clinical record face sheet printed 7-17-2024 revealed Resident #1 was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), major depression (mental illness causing sadness due to lack of chemicals in the brain that cause happiness) or (persistent depressed mood), epilepsy (disorder that causes abnormal brain function, seizures), and cognitive communication deficit (impaired thought processes). Record review of Resident #1's last quarterly MDS assessment was completed on 5-13-2024 revealed she had a BIMS score that required staff to complete due to Resident #1 was not able to complete the assessment due to memory problems, and Resident #1 had a functionality of requiring setup or clean-up assistance with most of her activities of daily living. Record review of Resident #1's PASRR Level 1 Screening with date of assessment 01-04-2024 revealed the following: -C090 Primary Diagnosis of Dementia-No -C0100 Mental Illness-No -C0200 Intellectual Disability-Yes -C0300 Developmental Disability-Yes There was no documentation in the chart of contact with the HHSC PASRR Unit for 5-7-2024 for (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676186 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 676186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027 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)