Health inspection·November 15, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR) Screening for 1 of 9 residents reviewed for PASRR (Resident #36). The facility failed to ensure Resident #36 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 10/28/2022. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of an undated face sheet indicated Resident #36 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including bipolar disorder and major depressive disorder. Record review of the annual MDS assessment dated [DATE] indicated, Resident #36 had a BIMS score of 13 (thirteen) indicating no impaired cognition. The MDS section for PASRR indicated Resident #36 did not have a serious mental illness. The MDS section, Psychiatric/Mood Disorder, indicated Resident #36 to have diagnoses of depression and bipolar disorder. Record review of physician orders current as of 11/15/2023 indicated an order dated 10/29/2022 for Resident #36 to receive one (1) Celexa 20 mg tablet daily for depression and an order dated 12/22/2022 for three (3) Depakote delayed release 250 mg tablets (750 mg) for bipolar disorder twice a day. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #36 was receiving antidepressant medications on a routine basis. Record review of Resident #36's PASRR Level 1 Screening completed on 10/28/2022 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of Resident #36's initial psychiatric evaluation dated 07/13/2023 indicated the resident had diagnosis of bipolar disorder and severe depressive episodes with psychotic features. During an interview with the MDS Nurse on 11/15/2023 at 9:40 AM, she said she was responsible for tasks related to PASRR and MDS processes. She said she was the MDS Coordinator at the time of (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: 675267 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 675267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbrier Nursing & Rehabilitation Center of Tyle 3526 W Erwin St Tyler, TX 75702 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)