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F0644
D

Failure to Coordinate PASRR Assessments for Residents with Mental Illness

Pleasanton, Texas Survey Completed on 07-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program for residents with newly evident or possible severe mental illness. Specifically, two residents with diagnoses of Major Depressive Disorder (MDD) were not identified as having a mental illness on their PASRR Level I screenings, which would have required a PASRR Level II assessment. For one resident, records showed a history of MDD and psychiatric mood disorder, but the PASRR Level I screening indicated no evidence of mental illness. The resident confirmed a long-standing diagnosis of depressive disorder and intermittent medication use. For the second resident, documentation included diagnoses of MDD, anxiety disorder, and care plan interventions for depression, yet the PASRR Level I screening also indicated no evidence of mental illness. Interviews with facility staff revealed that the MDS Coordinator was responsible for referring and screening residents for PASRR re-evaluations but was unaware of the mental illness diagnoses for these two residents due to not having reviewed all active diagnoses. The Director of Nursing confirmed that the MDS Coordinator should have referred these residents for evaluation in accordance with facility policy. The facility's policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders per the PASRR process, but this was not followed for the two residents in question.

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