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F0644
D

Failure to Implement PASRR Recommendations for Specialized Services

Lewisville, Texas Survey Completed on 09-16-2025

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 incorporate recommendations from the Pre-Admission Screening and Resident Review (PASRR) evaluation into the assessment, care planning, and transitions of care for a resident with intellectual and developmental disabilities. Specifically, the facility did not submit a complete and accurate request for specialized services in the required online portal within 20 business days after the annual interdisciplinary team meeting. The PASRR Comprehensive Service Plan recommended a repositioning wedge for the resident, but this intervention was not included in the resident's care plan or physician orders. The resident in question was an adult male with a history of frontal lobe executive function deficit following a cerebral infarction, bipolar disorder, schizophrenia, and other speech disorders. He was PASRR positive for intellectual and developmental disabilities and had functional quadriplegia, morbid obesity, and activity limitations. Despite these complex needs and the explicit recommendation for a repositioning wedge to address his tendency to lean to one side, the care plan and order summary did not reflect this intervention, and staff were unaware of the recommendation. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of awareness and follow-through regarding the PASRR recommendation. The MDS Coordinator was not informed of the need for a repositioning wedge, and the DON and Administrator were also unaware of the recommendation until it was brought to their attention during the survey. The facility's policy required proper screening and implementation of specialized services as determined by the interdisciplinary team, but this was not followed in this instance.

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