Health inspection·July 7, 2023

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 an assessment with Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort and for 1 of 1 resident reviewed for PASRR services coordination and assessment. (Resident #1) The facility failed to submit a complete and accurate NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #1 by a specific deadline and, as a result, Resident #1 had not received the CMWC. This failure could place residents with a positive PASRR evaluation at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #1's face sheet dated 07/06/2023 indicated Resident #1 was [AGE] year old male, admitted on [DATE], diagnosis included cerebral palsy. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 was diagnosed with cerebral palsy, used a wheelchair for mobility. Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had an ADL self-care performance deficit related to impaired balance and limited mobility. Listed interventions indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing and included PT/OT evaluation and treatment. Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had a positive PASRR status due to a diagnosis of cerebral palsy requiring specialized services, CMWC. The listed goal indicated Resident #1 would have all identified needs met. Listed interventions included facility will coordinate services with the local mental health authority. Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had a diagnosis of cerebral palsy. The listed goal was Resident #1 would be able to function at the fullest potential possible as outlined by the treatment team. Listed interventions included: Maintain good body alignment to prevent contractures . (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 3 Event ID: 676360 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 676360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Shoal 1011 Mainland Center Dr Texas City, TX 77591 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)