Health inspection·July 1, 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 incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for one (Resident #2) of 3 residents reviewed for PASARR services. The facility failed to submit a NFSS request within 20 days of the IDT meeting that was held on 2/4/2025 and failed to resubmit a NFSS request when it was initially denied ensuring the request was approved for specialized services for PASARR for Resident #1. This failure could place residents at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included:Resident #2 face sheet dated 6/30/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Schizoaffective disorder, depressive type (mental health condition), Major Depressive Disorder with psychotic features (mental health disorder characterized by depressed mood or loss of interest in activities), Unspecified lack of expected normal physiological development in childhood, reduced mobility, Spina Bifida (birth defect affecting the development of a developing baby's spinal cord), Paraplegia (loss of motor and sensory functions in the lower limbs, and generalized anxiety. Review of Resident #2's quarterly MDS dated [DATE] reflected he had a BIMS of 15 suggesting resident had no cognitive impairments. Review of Resident #2's care plan dated 6/30/2025 reflected Resident #2 has been identified as having a positive PASSAR evaluation related to [diagnosis] of Schizoaffective D/O Bipolar type and MDD with an intervention of coordinating services with a representative from the MHMR. Review of Resident #2's PCSP dated 2/12/2025 reflected an IDT meeting was held on 2/4/2025 for PASSAR services with nursing facility staff and local mental health authority staff in attendance with Resident #2. During an interview on 7/1/2025 at 9:45 am, Resident #2 stated he had attended his PASARR meeting back in February and was getting the services he needed. He stated he was unaware of the documentation required by the nursing facility of deadlines. He stated he was aware of the PASARR he was entitled to and had no concerns. During an interview on 6/30/2025 at 12:02 pm, the MDS Nurse stated Resident #2 was still on PASARR services and an IDT meeting was held with the local mental health authority on 2/4/2025. She stated she was on vacation at the time and was not aware the IDT meeting had taken place. She stated she found about the IDT meeting sometime later - she was not sure of the date and she contacted corporate, and they sat down and completed the NFSS. She stated it was already late at that point - past the 20 business days. She stated the NFSS is normally done by therapy, but the Director of Rehabilitation (DOR) didn't know how to do the NFSS so she and corporate completed it and submitted the form. She stated they did not know about the IDT meeting until they received an email from HHS (PASARR) on 4/21/2025. During an interview on 6/30/2025 at 1:50 pm, the DOR stated therapy did an evaluation on Resident #2 on 4/24/2025 and the first NFSS was submitted on 4/24/2025 and was denied on 5/8/2025. They submitted a new application on 5/16/2025 and it was accepted on 5/24/2025. Page 1 of 2 676409 676409 07/01/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated she was unaware of the IDT meeting that was held on 2/4/2025 and was not in the building at the time. She stated she was responsible for completing and sending in PASARR forms and not getting them in on time could cause the resident to not receive the services they required. During an interview on 7/1/2025 at 2:00 pm, the ADM stated he was aware of the PASARR issue with Resident #2, but this had happened under the previous administration. He stated to his knowledge there were no other issues with PASARR services in the facility, and it was just not meeting a deadline for documentation. Review of Facility Policy PASARR Documentation Policy dated 11/1/2017, reflected This policy is intended as a general guide for the PASARR process. Each facility develops a process for completion of the PASARR requirements as indicated by state specific policy and procedures.4. Any individual seeking admission to a Medicaid Certified nursing facility (NF) receives a PASARR Level I screening for any intellectual disability or (ID) or developmental disability (DD) or mental illness (MD) before or upon admission.5. If the PASARR Level I screening indicates the individual may have an ID, DD, or MI diagnosis, follow the state-specific process for completion of the Level II evaluation.6. If the Level II evaluation confirms an ID, DD or MD diagnosis the Facility collaborates with local resources when special services are necessary or required.7. If special services are required, the Facility will coordinate services per state policy and develop a care plan that addresses the specific needs.8. Care plan will be reviewed and updated as needed, quarterly and with significant change to evaluate and validate the effectiveness of interventions and make adjustments as necessary. 676409 Page 2 of 2