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F0645
D

Inaccurate PASRR Level 1 Screening for Mental Illness Diagnosis

West, Texas Survey Completed on 06-27-2025

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 assessment for one resident. The PASRR Level I Screening, completed prior to admission, did not indicate a diagnosis of mental illness, despite the resident having documented diagnoses of psychotic disorder with hallucinations, major depressive disorder, and anxiety disorder upon admission. The resident's face sheet and quarterly MDS assessment confirmed these mental health diagnoses, and the care plan included interventions for major depressive disorder. However, the PASRR Level I Screening form incorrectly reflected that the resident did not have a primary diagnosis of mental illness. Interviews with the DON revealed that the PASRR screening should have been positive due to the resident's mental illness diagnosis, but was incorrectly marked negative. The DON acknowledged responsibility for PASRRs and stated that a corrected screening should have been completed and sent to the local authority for evaluation. The facility's PASRR policy was requested but not provided prior to the survey exit. The Assistant Administrator also confirmed the expectation that PASRR Level 1 Screenings are completed accurately upon admission and corrected immediately if errors are found.

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