Health inspection·March 13, 2025

F 0825 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's care plan revealed the care planned areas: Focus: Resident has been identified has having PASRR positive status related to Mental Illness, Intellectual Disability, or Development Disability. Goal: Resident will have the specialized services recommended by local authority per PASRR Specialized Services Program as needed. Intervention: The Local Authority will be invited to the care plan meetings for review of Specialized Services. Residents Affected - Some Record review of the IDT meeting record dated 08/8/24 revealed that Resident #1 had selected to attend Day Habilitation. Record review of the Local intellectual and Developmental Disabilities Authorities Habilitation Service Plan dated 11/5/24 revealed Day Habilitation Services were pending. Record review of the Local intellectual and Developmental Disabilities Authorities Habilitation Service Plan dated 2/3/25 revealed Day Habilitation Services were still pending. In an interview with the Social Worker on 03/13/25 at 12:11 PM, she revealed there was only one resident who has inquired about day habilitation and that resident's family received the admissions paperwork to fill out but had not returned the admission paperwork back into the facility. The Social Worker could not recall how long the family had the paperwork but stated that the resident had a care plan meeting last month and the day habilitation admission paperwork was mentioned and that the MDS nurse would be the staff member to follow up with family to check the status. The Social Worker stated she was not aware if there was an allotted time frame that the paperwork had to be completed or if the member would lose out on that specialized service. In an interview with Resident #1 on 3/13/25 at 12:50 PM, he revealed that he had a meeting about day habilitation and his family member had selected a facility and he would still like to participate in activities to get him out of the facility for a while. In an interview with the Rehabilitation Director on 03/13/25 at 3:17 PM, he revealed Resident #1's interdisciplinary team meeting was last year date unknown. The Rehabilitation Director stated that Resident #1 was PASRR positive and requested a customized wheelchair, air mattress and day habilitation. The Rehabilitation Director stated that he had 20 days to complete for the durable medical equipment but was unsure of the process for day habilitation services. The Rehabilitation Director stated that he believed that the previous MDS nurse had provided Resident #1 family the admissions paperwork, but if the admission packet was sent to him, he would fill out everything that he could then have the resident representative come and sign, because It is the responsibility of the facility to get the residents services they require. Rehabilitation Director stated that if the resident missed out on services, they were willing to participate in, it would cause a decline in the residents quality of life. In an interview with the MDS nurse on 03/13/25 at 3:53 PM, she revealed that Resident #1 last PASRR meeting was held on 2/05/2025 and during the meeting Resident #1 was asked if they were still interested in participating in day habilitation and Resident #1 responded yes. The MDS nurse stated that she wasn't sure who was required to fill out the admissions paperwork but believed it should be the social worker, but between nursing, therapy and MDS they have the information required to fill the admission paperwork out and believed it was their responsibility to the resident to get them the services they need. All that should be required from the resident representative is if their signature is require. The MDS nurse stated they have 20 days to turn in the admission paperwork and to her knowledge there was no follow-up with the family prior to 2/25/2025 to ensure the 20-day deadline, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745006 If continuation sheet Page 2 of 3 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 745006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points Nursing and Rehabilitation 1901 N Hampton Rd Desoto, TX 75115 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)

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some which caused the resident to lose out on day habilitation services at least until the following quarterly meeting when they could reapply. In an interview with the Administrator on 03/13/25 at 4:36 PM, he revealed he had only been at the facility eight days and was made aware that Resident #1 was PASRR positive and had not received specialized services, but Resident #1's family member had been provided the admission packet for day habilitation, but not sure how long it had been since they received it. The Administrator stated that it would be his expectation that if a resident is agreeable to services that those services should be made available and that if the facility was made aware that the family representative had difficulty filling out the paperwork, the facility should be willing to assist filling out the paperwork except for the signature. In an interview with Resident #1 on 3/13/25 at 5:15PM, he acknowledged to the Administrator that he had heard about going to day habilitation to participate in activities and therapy. When the administrator asked if he wanted to participate in that, Resident #1 stated that he would like to attend. Requested the facility PASRR policy, but administrator stated he was not able to locate the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745006 If continuation sheet Page 3 of 3