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F0645
D

Failure to Complete Accurate PASRR Screenings for Residents with Mental Disorders

Keene, Texas Survey Completed on 07-31-2025

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 provide accurate Preadmission Screening and Resident Review (PASRR) screenings for six residents with mental disorders or intellectual disabilities. Specifically, the facility did not complete accurate PASRR Level One screenings for three residents who were admitted with negative PASRR Level 1 results despite having mental illness diagnoses. Additionally, the facility did not ensure that three other residents' PASRR Level One screenings accurately reflected their mental illness diagnoses, nor did it submit corrected PASRR Level One screenings for these individuals. Record reviews revealed that the affected residents had various mental health diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, depression, schizoaffective disorder, psychotic disorder, schizophrenia, bipolar disorder, and major depressive disorder. Many of these residents were also prescribed psychotropic medications such as antipsychotics and antidepressants. Care plans for these residents included interventions to monitor for symptoms such as anxiety, agitation, aggression, social withdrawal, and sleeplessness, indicating ongoing mental health concerns that should have been captured in the PASRR process. Interviews with facility staff, including the MDS Coordinator and Social Worker, confirmed that the PASRR process was not consistently followed. The MDS Coordinator acknowledged that residents without a completed PASRR Level 1 screening would not receive necessary services and that the facility would not be reimbursed. The Social Worker described the process for handling PASRR-positive residents and indicated that residents should not be admitted without a PASRR. However, documentation showed that PASRR screenings were either not completed or not accurately reflecting residents' mental health diagnoses, resulting in a lapse in required screenings and potential services.

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