F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure individuals with mental health disorders were
provided an accurate PASARR for 1 of 2 residents (Residents #36) reviewed for PASARR Level 1
screenings.
Residents Affected - Few
The facility failed to notify the local authority of the PASARR I screen for Residents #36.
This failure could affect residents with mental illness placing them at risk for a diminished quality of life and
not receiving necessary care and services in accordance with individually assessed needs.
Findings included:
Record review of a Face Sheet dated 06/05/25 for Resident #36 revealed a [AGE] year-old female admitted
initially to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included post-traumatic stress
disorder (is a mental health condition that's caused by an extremely stressful or terrifying event - either
being part of it or witnessing it), bi-polar disorder, in full remission, most recent episode depressed (is a
serious mental illness characterized by severe mood swings. Remissions refers to a state where mood
symptoms are absent or minimal), Parkinson's disease without dyskinesia, without mention of fluctuations
(the condition in its state where these involuntary movements are not present), other insomnia (sleep
difficulties that do not link to any other health conditions. It can be acute or chronic).
Record review of Resident #36's diagnosis report revealed that she was diagnosed with post-traumatic
stress disorder upon admission and bi-polar disorder, in full remission on 03/13/23.
Record review of Resident #36's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated
cognitive intact in section C.
Record review of Resident 36's care plan dated 03/24/2025 revealed a focus that Resident #36 had a
trauma r/t history of PTSD; she had mood problems related to the disease process; and she has the
potential to demonstrate physical behaviors related thx of PTSD. With a goal of no evidence of emotional,
physical, and psychological problems; improved mood state and happier, calmer, appearance, no s/sx of
depression, anxiety, or sadness; effective coping skills through the review date. Interventions in place were
to administer mediations as ordered, monitor/document for side effects and effectiveness, behavioral health
consults as needed, encourage resident to attend care conference to express preferences and participate
in care plan process, monitor/record/report to MD mood patterns s/sx of depression, anxiety, or sad mood.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
455637
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455637
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wellington Rehabilitation and Healthcare
1802 S 31st
Temple, TX 76504
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Record review of Resident #36's PASARR Level 1 Screening dated 03/13/23 revealed the resident did have
a Mental Illness, Intellectual Disability, or Developmental Disability in section C.
During an interview with the MDS Coordinator on 06/06/2025 at 2:25 PM, reflected she does the MDS for
the residents and the resource nurse reviews it to make sure it is correct. She stated if it is done incorrectly,
she can go in, complete the modification, and sign it. She stated failure to enter the PASARR request in a
timely manner could result in the resident not receiving the psych services and not get some DME they
may have qualified for. She has submitted a Negative PASARR Level 1 form 1012 for resident dated
6/6/2025.
During an interview with the ADM on 06/06/2025 at 2:40 PM, reflected his expectation is to clarify and
place his trust in his team to meet the expectations and communicate any needs. He expected them to
communicate with the family on how the resident are doing. He stated the MDS Coordinator and the MDS
clinical resource is responsible for making sure the MDS are accurate. He stated not submitting the
PASARR in a timely manner to the local authorities, this failure could result in the resident not receiving
services.
Record review of the facility's policy, PASRR Policy and Procedure undated reflected: Policy: The facility will
designate as individual to follow up on ALL residents have receive a PASARR Level I screening. If the
facility serves a resident with a positive PASARR Level I screening, the facility MUST have obtained a
PASARR Level II evaluation from the Local Authority or have documented attempts to follow up with the
Local Authority to obtain the PASARR Level II evaluation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455637
If continuation sheet
Page 2 of 2
