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F0645
D

Failure to Complete PASRR Level II Evaluation for Resident with Mental Illness

Kaufman, Texas Survey Completed on 01-07-2026

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 that the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected a resident's status and did not complete a required PASRR Level II evaluation for a resident identified as having a mental illness. The resident, a female with diagnoses including schizophrenia, mood affective disorder, and depression, was admitted with a PASRR Level I screening indicating mental illness. Despite this, there was no evidence in the electronic medical record that a PASRR Level II evaluation was completed to determine eligibility for specialized services. Interviews with facility staff confirmed that the MDS Nurse, responsible for reviewing PASRR Level I screenings and submitting corrections or further evaluations, did not complete or submit the necessary PASRR Level II for the resident. The administrator and DON both acknowledged that the failure to complete the PASRR evaluation could result in the resident not receiving appropriate services. Facility policy required review and submission of PASRR forms prior to admission and prompt contact with the Local Authority for specialized services, which was not followed in this case.

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