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F0645
D

Inaccurate PASRR Level I Screenings for Residents with Mental Illness

Beaumont, Texas Survey Completed on 06-11-2025

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 ensure the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I assessments for two residents. For both residents, the PASRR Level I screening forms did not indicate a diagnosis of mental illness, despite both having documented diagnoses of schizophrenia upon admission. One resident had a diagnosis of disorganized schizophrenia with an onset date several years prior to admission and was receiving antipsychotic and antianxiety medications. The other resident had a diagnosis of schizophrenia, intact cognition, and was also receiving antipsychotic medication. In both cases, the PASRR Level I forms incorrectly marked 'no' for mental illness. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for completing the PASRR Level I screenings, acknowledged the error and stated that both residents should have been marked as having a mental illness. The ADON and DON reported not being involved with PASRR processes. The facility's policy required review of the PASRR Level I form for accuracy prior to admission, but this was not followed, resulting in the inaccurate documentation for both residents.

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