The resident, identified in inspection records as a woman with multiple serious conditions including major depressive disorder, anxiety disorder, end-stage renal disease and bilateral knee arthritis, was approved for a customized manual wheelchair and other disability services. But eight months after her admission, the facility still had not filed the necessary forms to secure those services.
Federal inspectors found the violation during a September complaint investigation. The facility's failure violated requirements for Pre-Admission Screening and Resident Review services, known as PASRR, which ensure nursing home residents with intellectual disabilities receive specialized care.
The woman was evaluated for disability services on December 27, 2024, and found positive for intellectual disability. A care plan dated January 29, 2025, specifically recommended she receive a customized manual wheelchair. Yet when inspectors arrived in September, they found no evidence the facility had submitted her Nursing Facility Specialized Services form.
MDS Coordinator A told inspectors she never submitted the required paperwork because the resident had no payer source at the time. She said she was not aware she could submit the form without the resident being approved for Medicaid first.
The coordinator acknowledged her failure could prevent residents from receiving services needed for their wellbeing.
Federal regulations require facilities to submit PASRR paperwork within 20 days of the interdisciplinary team meeting that recommends services. The woman's case exceeded that deadline by months.
PASRR evaluations identify residents who need specialized services beyond standard nursing home care. For residents with intellectual disabilities, these services can include behavioral interventions, therapeutic activities, and adaptive equipment like the wheelchair recommended for this resident.
The Administrator told inspectors that MDS Coordinator A was responsible for handling PASRR submissions. When inspectors requested the facility's PASRR policy on September 4, staff failed to provide it before the inspection concluded.
The woman's medical record revealed the complexity of her conditions. Beyond profound intellectual disabilities, she suffered from prediabetes, gastric ulcer, anemia, and age-related osteoporosis. Her bilateral knee arthritis likely made mobility particularly challenging, making the recommended wheelchair crucial for her daily functioning.
The inspection report noted that residents who are PASRR positive face risks when they don't receive required specialized services. Without appropriate interventions and equipment, their quality of life can decline and their health can deteriorate.
The facility's failure represents more than administrative oversight. For residents with intellectual disabilities, PASRR services often mean the difference between thriving in a nursing home environment and experiencing unnecessary decline.
The woman's case illustrates how bureaucratic confusion can leave vulnerable residents without care they need. The MDS coordinator's misunderstanding about Medicaid requirements meant months of delay for services already deemed necessary by evaluators.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for the woman waiting for her wheelchair and other services, the impact was immediate and personal.
The facility's inability to produce its PASRR policy when requested suggests systemic problems with how staff understand and implement disability services requirements. Without clear procedures, other residents with intellectual disabilities could face similar delays.
Friendship Haven's violation occurred despite clear federal mandates. Facilities must coordinate with PASRR programs and refer residents for services as needed. The 20-day submission deadline exists specifically to prevent the kind of prolonged delay this resident experienced.
The woman remains at Friendship Haven, her specialized services still pending as bureaucratic processes continue. Her case stands as evidence of how administrative failures in nursing homes can deny residents the very services designed to improve their lives.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Friendship Haven Healthcare and Rehabilitation Cen from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Friendship Haven Healthcare and Rehabilitation Cen
- Browse all TX nursing home inspections