Health inspection·June 16, 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 interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care 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 IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR 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 06/16/2025 revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: muscle weakness (decreased strength), muscle wasting and atrophy (loss of strength), unspecified lack of coordination (unable to control movement), osteoarthritis (tissue wears down), genetic related intellectual disabilities (abnormalities in genes or chromosomes), obesity (excessive body fat). Record review of Resident #1's MDS annual assessment dated [DATE] revealed a BIMS score of 15 meaning intact cognitive response. Record review of Resident #1's care plan dated revision date 12/10/2024 revealed Resident #1 is PASRR positive, will participate in quarterly care plan meetings with PASRR representative/social worker, Coordination of PASRR services and Individual Service Plan developed by PASRR representative/social worker. Record review of Resident #1's PCSP dated 12/19/2024 revealed IDT meeting was held on 12/19/2024. Attendees included the resident, the PASRR habilitation coordinator, the Social Worker, MDS RN, and Resident #1. The following NFSS were identified and confirmed: Customized Manual Wheelchair - 3 indicated on-going. During an interview on 06/16/2025 at 9:40 AM, the ADM stated he became aware of a concern with Resident #1's CMWC recently around the end of May 2025. He stated the MDS nurse, and the DOR advised him they were having a hard time getting paperwork completed for Resident #1 for a new customized manual wheelchair. He stated he looked into their concerns and realized they were needing to have the resident assessed for possibly a new wheelchair. He stated the customized manual wheelchair Resident #1 Page 1 of 3 676259 676259 06/16/2025 Shinnery Oaks Community 711 West Broadway Denver City, TX 79323

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had, was two years old. He stated he was told a recommendation was made during an IDT meeting for a new CMWC. He stated he reached out to the DME company for them to evaluate Resident #1 and the CMWC he currently had. He stated Resident #1 was evaluated by the DME Rehab Tech and Resident #1 did not qualify for a new CMWC. He stated Resident #1 did not have a significant medical change of condition that would qualify for a new CMWC. He stated he sent out an email to the DON, MDS nurse, DOR, SW and BOM about the process for completing information and submitting NFSS forms on 05/30/2025. He stated he did go into the LTC portal and fill out the forms to see the process, but he did not submit the form. He stated the facility did not complete the NFSS form in the LTC portal within the 20 days. During an interview on 06/16/2025 at 10:15 AM, the SW stated she did attend an IDT PASRR meeting for Resident #1 in December 2025 and it was mentioned during the meeting that Resident #1 might benefit from a new CMWC. During an interview on 06/16/2025 at 10:30 AM, the MDS nurse stated it would have been in November or December of 2025 that she attended a PASRR meeting for Resident #1. That during the meeting it was mentioned that therapy would need to start the process for the CMWC for Resident #1 and coordinate with MDS on that process. She stated the DOR was working on a form for the process and he realized he was not qualified to sign the form and that was when they went to the ADM and asked for assistance. During an interview on 06/16/2025 at 12:12 PM, the DOR stated he did not attend the PASRR meeting in December 2025 with Resident #1. He stated he was not familiar with the PASRR process and reached out to colleagues for assistance. He stated he was not qualified to make assessments for CMWC and could not sign the form for the CMWC. He stated the facility did have the DME company evaluate Resident #1 for a new CMWC and at that time the DME company said repairs were needed to the CMWC and once the repairs were made, they would re-evaluate Resident #1 to see if a new CMWC was needed. During an interview on 06/16/2025 at 12:40PM, Resident #1 stated that his wheelchair worked just fine and was comfortable for him. Record review of the email from the ADM dated 05/30/2025 sent to DON, DOR, SW, MDS and BOM for training purposes for PASRR recommendations revealed the following: 3. NFSS Form Completion: The nursing facility provider must complete the NFSS form, including all required information, such. as the resident's demographics, the therapist's assessment findings, and the physician's order. For customized manual wheelchairs, the NFSS form needs to be completed by a licensed therapist. - Worksheet is to be completed by Therapy and that information is to be imputed into SlmplelTC by MDS - MDS will upload the following forms into SimpletlTC 1. CMWC Signature page - Therapist, Physician and Administrator signature page 676259 Page 2 of 3 676259 06/16/2025 Shinnery Oaks Community 711 West Broadway Denver City, TX 79323

F 0644 2. PT or OT Evaluation or Cert/progress notes signed by physician out of PCC (Therapy to provide) Level of Harm - Minimal harm or potential for actual harm 3. Supplier Acknowledgement page - Rehab Engineer 4. Manufacturers page - Estimate of cost Residents Affected - Few 5. QRP - Rehab Engineer Certificate 6. Once this is completed, we submit forms and wait for response from THHS. Once we have approval for order, it is the facility responsibility to pay for wheelchair upfront and then request for reimbursement 7. Receipt - CMWC - To be signed by therapist and Administrator after wheelchair is received and both agree that it meets the resident's needs. The completed NFSS form is submitted through the Texas Medicaid and Healthcare Partnership's LTC Online Portal. 5. Authorization and Payment: wheelchair is authorized, and the nursing facility can proceed with purchasing it. 6. Provider Action Required: If any rejection error messages occur during the workflow process, the provider must take action to correct the request and resubmit it. Record review of the facility policy: Resident Assessment - Coordination with PASRR Program Policy: The facility coordinates assessments 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. Policy Explanation and Compliance Guidance: 7. Recommendations, such as any specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transactions of care. 676259 Page 3 of 3