Health inspection·June 29, 2022

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 the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #60 and Resident #33) of six residents reviewed for PASRR Screenings. Residents Affected - Some 1. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #60. The resident did not receive a PASRR Level II assessment Evaluation. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #33. The resident did not receive a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: 1. Review of Resident #60's face sheet, dated 06-29-22, reflected she was a [AGE] year-old female with diagnoses including schizoaffective disorder (mental health disorder with a combination of schizophrenia symptoms) and dementia. Review of Resident #60's PASRR Level 1 screen dated 02-01-22, reflected, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness? No. 2. Review of Resident #33's face sheet, dated 06-29-22, reflected she was a [AGE] year-old female with diagnoses including bipolar disorder (mental health disorder) and dementia. Review of Resident #33's PASRR Level 1 screen dated 04-26-21, reflected, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness? No. Interviews on 06/28/22 at 3:01 PM and 06/29/22 at 2:42 PM with the MDS Nurse revealed she had been completing PASRR evaluations for a few months. She said she was not employed at the time the PASRR Level 1 screens were completed for Residents #33 and #60. She said they did not have a positive PASRR Level 1 screen because they both had a diagnosis of dementia . An interview on 06/29/22 at 1:36 PM with the DON revealed she did not monitor the facility PASRR process, and that the SW was supposed to, but she was still a new employee. She said if a resident did not receive the appropriate PASRR Level 1 screen they could be denied services. (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: 675625 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 675625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pasadena 4300 Vista Rd Pasadena, TX 77504 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)