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. Page 1 of 2 675625 675625 06/29/2022 Avir at Pasadena 4300 Vista Rd Pasadena, TX 77504

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview on 06/29/22 at 1:42 PM with the SW revealed she did not monitor the facility PASRR process. She said if a resident did not receive an accurate PASRR Level 1 screen screening the resident might not receive services that PASRR could provide. An interview on 06/29/22 at 3:06 PM with the Administrator revealed no one was double-checking PASRR assessments . The Administrator said the facility needed more PASRR training. Review of the facility's policy and procedure Preadmission Screening and Resident Review (PASRR), not dated, reflected, Procedure: 1. The facilities designated staff will review all potential admission for possible positive PASRR conditions and ensure CMS preadmission guidelines are followed. 675625 Page 2 of 2