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F0644
D

Failure to Incorporate PASRR Recommendations and Submit Required NFSS Documentation

Friendswood, Texas Survey Completed on 09-04-2025

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 a PASRR (Preadmission Screening and Resident Review) evaluation into the assessment, care planning, and transition of care for a resident with profound intellectual disabilities. Specifically, the PASRR evaluation recommended that the resident receive a customized manual wheelchair, but this recommendation was not included in the resident's assessment or care plan. Additionally, there was no evidence in the clinical records that the required NFSS (Nursing Facility Specialized Services) form was completed or submitted for the resident. Interviews revealed that the MDS Coordinator did not submit the NFSS form because the resident did not have an approved Medicaid payer source at the time, and the coordinator was unaware that submission was required regardless of payer status. The facility's policy on PASRR submission was requested but not provided before the survey exit. The resident involved had multiple diagnoses, including profound intellectual disabilities, major depressive disorder, anxiety disorder, osteoarthritis, prediabetes, gastric ulcer, anemia, osteoporosis, and end-stage renal disease.

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