Health inspection·June 6, 2024

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 Page 1 of 2 675495 675495 06/06/2024 Laurel Court 3830 Mustang Road Alvin, TX 77511

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 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 . 675495 Page 2 of 2