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 . Page 1 of 3 676360 676360 07/07/2023 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

F 0644 OT to monitor/document and treat at indicated .Use assistive devices recommended . Level of Harm - Minimal harm or potential for actual harm PT to monitor/document and treat at indicated . Residents Affected - Few Record review of Resident #1's PCSP form dated 02/08/2023 indicated Resident #1, diagnosed with IDD, had an initial IDT meeting for specialized services review on 02/08/2023. This PCSP form indicated the IDT members recommended Resident #1 receive new services of CMWC, Specialized Assessment OT and Specialized Assessment PT. Record review of a Simple LTC PASRR NFSS Activity for CMWC/DME assessment dated [DATE], signed by OT 05/22/2023 and signed by the physician 06/05/2023 indicated Resident #1 has a history of very thin, fragile skin, increased pressure at bony prominences due to low weight and malnutrition in community prior to entering the facility and decreased skin integrity with history of previous sacral skin breakdowns .due to severity of postural deficits and deformities. The section titled Describe Orthopedic conditions noted Resident #1 presents with severe and significant tightness, tone and contractures .contractures, scoliosis and severe lower extremities contractures .Resident #1 presents with significant deficits, poor balance, diminished sensation/cognitive awareness, very poor upper extremity and lower extremity strength and severe contractures . Per this same assessment the Reason Code for this assessment indicated HHSC did not receive information previously requested from the nursing facility necessary to establish eligibility for the service or item. Record review of PASRR Compliance Call Report for March 2023 spreadsheet for Resident #1's IDD services PASRR Unit indicated the following: *IDT meeting was held on 02/08/2023, *PCSP was created on 02/21/2023, *IDT date plus 30 days was 03/10/2023, *NF contacted 05/16/2023, *Due date for NF to submit NFSS form in LTC portal for DME/CMWC was 05/22/2023. Record review of a Simple LTC PASRR NFSS Activity Portal History dated 06/12/2023 at 10:13 a.m. for Resident #1 indicated the NFSS form request for CMWC/DME was not submitted within 30 calendar days of the IDT meeting. During an interview on 07/06/2023 at 4:15 p.m., the Administrator said OT/PT Specialized Assessment submissions were late in the LTC Portal and Resident #1 had not received the CMWC. During an interview on 07/06/2023 at 5:20 p.m., the MDS/PASRR Nurse said on 05/19/2023 the facility entered the measurements Resident #1's CMWC but had to wait on additional information from DME, which was not received 06.12.2023. The MDS/PASRR said the same day (unknown) the facility received the information from the DME it was submitted in the portal. She said Resident #1 had not received the CMWC. Record review of the March 2019 facility policy entitled admission Criteria (provided by the facility as the PASRR policy), section Nursing Facility Responsibilities read, 1 .b. admit residents who 676360 Page 2 of 3 676360 07/07/2023 The Shoal 1011 Mainland Center Dr Texas City, TX 77591

F 0644 Level of Harm - Minimal harm or potential for actual harm can be cared for adequately by the facility .6. Residents are admitted to this facility as long as their needs can be met adequately by the facility . Record review the facility provided CMS 672 dated 07/05/2023 indicated there was one resident with intellectual and/or developmental disability. Residents Affected - Few 676360 Page 3 of 3