Health inspection·December 30, 2025

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 assessments with the resident review (PASARR) program under Medicaid in subpart C for 1 (Resident #1) of 2 residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the initial IDT meeting held on 6/14/24.This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.Findings included:Record review of Resident #1's face sheet dated 12/16/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: encephalitis (inflammation of the brain) and encephalomyelitis (inflammation of the brain and spinal cord), demyelinating disease (affects the protective cover around nerve cells) of central nervous system, manic episode (a period of abnormally elevated extreme changes in mood, behavior, activity, and energy level) without psychotic symptoms, bipolar disorder (a mental health condition that causes extreme mood swings), functional quadriplegia (a complete inability to move due to severe disability or frailty), and major depressive disorder.Record review of Resident #1's most recent quarterly MDS annual assessment dated [DATE] indicated a BIMS score of 15 meaning intact cognitive response.Record review of Resident #1's care plan dated revision dated 1/7/25 indicated Resident #1 has been identified as having PASRR positive DD and has refused all services. Interventions were: if Resident #1 changes his mind regarding services, staff to contact county with any changes. Will conduct annual meetings. Record review of Resident #1's PCSP dated 6/14/24 revealed the initial IDT meeting was held on 6/14/24. Attendees included Resident #1, LIDDA- Habilitation Coordinator, DON, DOR, MDS Coordinator A, MDS Coordinator B, and Resident #1's RP. The following NFSS were identified and confirmed: Customized Manual Wheelchair, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT and Specialized ST - all services were coded 2 indicated new.During an interview on 12/16/25 at 4:24 pm, with MDS Coordinator A and the DOR, MDS Coordinator A said the initial IDT meeting was held on 6/14/24. The DOR said Resident #1 was approved for PT, OT, and ST and Resident #1 refused all the evaluations. MDS Coordinator A said this was the first time they ran into a situation where the resident refused services, and she was not sure what to do with this situation. MDS Coordinator A said she contacted the PASRR representative from the Local Authority for guidance when the resident refused. MDS Coordinator A said initially Resident #1, and his RP were ok with the services offered but then Resident #1 refused. MDS Coordinator A said they had an annual meeting with Resident #1 recently and he refused again.During an interview on 12/17/25 at 9:15 am, with Resident #1, he said he refused services because he was going to get steroids to help him walk.During an interview on 12/30/25 at 9:04 am with Resident #1's RP, the RP said Resident #1 needed to see a psychiatrist because he had mental issues. The RP said she had trouble with Medicaid insurance because Resident #1's physician no longer takes his insurance.During an interview on Page 1 of 2 676195 676195 12/30/2025 Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/30/25 at 10:37 am with MDS Coordinator A she said the DOR is normally responsible for submitting the NFSS form in the LTC portal. MDS Coordinator A said they discussed the NFSS form as a team and checked the portal daily to see if the NFSS form was approved. MDS Coordinator A said Resident #1 was able to make his own decisions. She said Resident #1 would probably benefit from the services, but they cannot force him to do anything.During an interview on 12/30/25 at 11:15 am with the Administrator, he said the MDS Coordinator, and the DOR were responsible for submitting the NFSS form. He said he thought the hiccup was when Resident #1 initially said yes to the services and then refused. The Administrator said there was no risk to Resident #1 because he had refused all services.Record review of the facility's PASRR policy not dated read in part . Ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs . 676195 Page 2 of 2