Health inspection·June 25, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on the interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for #25, whose records were reviewed for PASRR services. Residents Affected - Few The facility failed to get a PASRR eval when Resident #25's Level 1 PASRR screening indicated the resident had mental illness diagnoses of schizoaffective disorder, bipolar type, and anxiety. Findings included: This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The facility failed to complete a PASRR screening on Resident #25. Findings included: Record review of Resident #25's face sheet dated 06/25/2025 revealed the resident was admitted to the facility 08/24/2024 with diagnoses that included: Unspecified dementia, schizoaffective disorder, bipolar type (a mental health condition involving psychotic symptoms like hallucinations and delusions alongside mood episodes of mania and sometimes depression), and borderline intellectual functioning. Resident #25 was diagnosed, schizoaffective disorder, bipolar type on 7/18/2024. Record review of Resident #25's quarterly MDS assessment, completed on 06/04/2025, Section C, revealed a BIMS score of 08/15, indicating moderate cognitive impairment. Section I (Active Diagnoses) indicated Resident #25 had diagnoses of schizophrenia (e.g., schizoaffective and schizophreniform disorders). Section N (Medications) indicated Resident #25 was taking antipsychotic medications. Record review of Resident #25's care plan, dated 04/02/2025, revealed Resident #25 exhibits/reports mood problem related to mood disturbance and Psychosis. She was receiving the antipsychotic medication Seroquel, and the interventions included monitoring for behavior management to reassure the patient about the progress he is making towards goals. Record review of the documents in Resident #25's electronic health record revealed a PASRR 1 evaluation dated 08/27/2024, indicating the resident did not have a primary diagnosis of dementia, mental illness, intellectual disability, or developmental disability. Page 1 of 2 675360 675360 06/25/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #25's physician order, dated 12/27/2024, revealed an order for Seroquel Oral Tablet, 50 MG, give 1 tablet by mouth two times a day related to schizoaffective disorder, bipolar type. The order date and start date was 12/27/2024. During an interview on 06/25/2025 at 3:13 PM, the DON stated that Resident #25's Level II PASRR evaluation was not completed . The DON explained that either the MDS coordinator or the ADON completes the Level II PASRR screening at the facility. She mentioned that the resident received more services through Part B than with PASRR services . Resident #25 was not receiving services through PASRR. The DON also noted that the resident was receiving therapy services, but those services were not provided through PASRR. During an interview on 06/25/2025 at 3:13 PM, the ADON MDS Minimum Data Set coordinator said that she was primarily responsible for handling the PASRR screenings, although the MDS occasionally performs them. The ADON stated she conducted the PASRR screening for Resident #25. She mentioned that if a resident comes from the hospital, there could be an issue because sometimes they do not provide a PASRR. The ADON said she checks whether a resident was receiving NSF and Medicaid services. ADON that when a resident gets a new diagnosis, they get a new PASRR screening. She also stated that if the PASRR was not completed on time, it could result in a delay in services. Review of facility policy dated March 2019 and titled admission Criteria reflected the following: 9. All new admissions and re-admissions are screen for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid preadmission screening and resident review process. a. The facility conducts a level I PASARR screens for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the State PASARR representative for the level II evaluation and determination screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible evident MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state designated authority. 675360 Page 2 of 2