Health 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 Page 1 of 2 676186 676186 07/17/2024 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0644 Resident #1. Level of Harm - Minimal harm or potential for actual harm During an observation on 7-17-2024 at 09:15 AM of Resident #1, she was observed in the front lobby dressed well sitting in a chair. Resident #1 appeared in good condition. Resident #1 did not respond to introduction or questions. Resident #1 just stared at this surveyor. Residents Affected - Few During an interview on 7-16-2024 at 08:07 AM the PSPU coordinator reported that the facility contacted the HHSC PASRR Unit on 5-7-2024. She stated that a NFSS form was required to be provided to the HHSC PASRR Unit by 5-10-2024 and as of 7-16-2024 the form had not been received. During an interview on 7-17-2024 at 02:13 PM the MDS Coordinator verified that she was the person who entered everything into the HHSC PASRR Unit portal and that she did not enter any information for Resident #1 on 5-7-2024. When presented with the information that Administrator A had contacted the HHSC PASRR Unit on 5-7-2024, the MDS Coordinator reported that Administrator A was a former administrator and that Resident #1 had been in the hospital just prior to 5-7-2024. The MDS Coordinator report that Administrator A may have contacted HHSC PASRR Unit by mistake, that she (the MDS Coordinator) was not aware of any contact that was made with the HHSC PASRR Unit for the date of 5-7-2024. The MDS Coordinator was aware that that initial contact on 5-7-2024 did result in the need for a NFSS (Nursing Facility Specialized Services) form to be provided to HHSC PASRR Unit within three days and that due to the former administrator not telling anyone of her contact the form was most likely not provided and we were out of compliance. The MDS Coordinator reported that with the facility having so many recent issues with management changes, Resident #1 having issues with her Medicaid approval, and the changes with the new ownership of the facility, that the coordination just got caught up in all that. The MDS Coordinator reported that if the coordination with the HHSC PASRR Unit was not followed then a resident definitely can have problems if their care is not coordinated. Record review of the facility provided policy titled Resident Assessment - Coordination with PASRR Program) date implemented 9-1-2023 revealed the following: Policy: This facility coordinated assessment with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policies Explanation and Compliance Guidelines: -The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level II PASRR evaluation and determination. 676186 Page 2 of 2