Health inspection·April 3, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for 1 of 8 residents (Resident #1) reviewed for resident assessment. The facility failed to ensure Resident #1's PASRR Level I screening reflected her mental illness diagnosis. This failure could place residents at risk of not receiving specialized services for their mental illness. Findings included: Record review of Resident #1's admission Record dated 4/3/25 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, bipolar type (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), anxiety disorder, depression and major depressive disorder severe with psychotic symptoms. Record review of Resident #1's discharge-return anticipated MDS assessment, dated 3/19/25 revealed her cognitive skills for daily decision making were moderately impaired. Record review of Resident #1's care plan dated 4/2/25 indicated she used antidepressant medication related to depression, anxiety, schizoaffective disorder, bipolar type, and major depressive disorder recurrent severe with psychotic symptoms. Record review of Resident #1's PASRR Level I screening dated 8/28/23 indicated there was no evidence or an indicator that the resident had a mental illness. Resident #1 did not have a primary diagnosis of dementia. In an interview on 4/2/25 at 3:49 p.m. the MDS nurse said Resident #1 was positive for mental illness and did not have a dementia diagnosis. She said the (inaccurate) PASRR should have been caught during admission and she would submit another PL1 screening, She said she should have completed an audit of all residents with a schizo diagnosis. She said the purpose of the PASRR screening was to ensure the resident got adequate care and help to go out into Page 1 of 2 675365 675365 04/03/2025 Pasadena Post Acute 4006 Vista Rd Pasadena, TX 77504

F 0644 the community. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/3/25 at 2:55 p.m. the Administrator said staff should double check the PASRR to ensure no diagnoses were missed. He said the facility did not have a great policy in place but moving forward they would ensure routine audits were completed on PASRRs. He said the purpose of the PASRR screening was to determine if the resident met qualifications for benefits of PASRR. He said he did not believe there was a risk for an inaccurate PASRR screening because the facility had good psych providers to address the residents' needs. Residents Affected - Few Record review of the facility's admission Criteria policy dated March 2019 read in part, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen 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 that 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 (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority . 675365 Page 2 of 2