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 Preadmission Screening and Resident Review (PASRR) Screening for 1 (Resident
#81) of 4 residents reviewed for resident assessments.
Residents Affected - Few
The facility failed to ensure Resident #81 had a PASRR on file for his bipolar and depression diagnoses.
This failure could place residents with mental disorders and developmental disabilities at risk of not
receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial
well-being and quality of life.
Findings included:
Record review of Resident #81's face sheet revealed a [AGE] year-old male admitted on [DATE]. His
diagnoses were bipolar disorder (A serious mental illness characterized by extreme mood swings), and
depression.
Record review of Resident #81's Quarterly MDS assessment dated [DATE] noted Resident #81 had a BIMS
score of 5 out of 15 which indicated he was cognitively severely impaired. Section, Active Diagnoses noted
the resident with bipolar disorder and depression. Section, Antipsychotic medications noted the resident
was on antipsychotic medication.
Record review of Resident #81's care plan dated 03/11/24 reflected Resident #81 had not been care
planned for his bipolar disorder.
Record review of Resident #81's medical record revealed one PASRR Level 1 Screening dated 03/11/24
with negative results for mental illness. There was no evidence a new screening was performed when
Rresident #81 was admitted with a diagnosis of bipolar disorder.
During an interview on 06/05/24 at 11:18 AM with the MDS Coordinator, he said he had been in his position
for a little over a year. He said he was responsible for reviewing and completing the PASRRs and ensuring
that all residents with a mental illness diagnoses were referred for PASRR evaluation for services. He said
he must have overlooked this Rresident #81's mental illness diagnosis. He said the risk of not having and
accurate PASRR Screening and evaluation was the resident was not receiving service such as and
community services that they qualify for.
Interview with the DON on 06/06/24 at 12:20 PM, she said the Resident #81's PASRR was completed
(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:
675495
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
675495
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Court
3830 Mustang Road
Alvin, TX 77511
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
upon admission on [DATE]. She reported she was unaware an additional PASRR needed to be completed.
She reported the MDS Coordinator was responsible for PASRR's. She said she was unaware of risk or
negative effects of not completing the correct PASRR screening or PASRR evaluation.
Interview on 6/6/2024 at 12:26 PM with the Administrator, she said PASRR screening was completed prior
to admission to the facility. She reported they followed the Texas Health and Human Services guidelines for
PASRR screenings. She said the risk to the resident of not having an accurate PASRR screening and
assessment would be that the resident would not receive mental health services to which they are entitled.
Record review of Record review of the facility's Detailed Item by Item guide for referring entities to complete
the PASRR Level 1 Screening policy dated 6/2023 read in part . Purpose. The PL1 screening form is
designed to identify individuals who are suspected of having a mental illness (MI), intellectual disability (ID),
or developmental disability((DD). All people who are confirmed as having MI ID RTD's are identified as
PASRR positive. Administering the PE helps to ensure that PASRR positive individuals are placed in the
most integrated residential setting of their choice, where they can receive the specialized services needed
to improve and maintain the best level of functioning .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675495
If continuation sheet
Page 2 of 2
