Inspection·May 29, 2025

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 (PASARR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #13) reviewed for PASARR Level I screenings. Residents Affected - Few 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #13. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (bipolar disorder with an onset date of 02/25/25) was present upon Resident #13's admission date on 02/26/25. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #13's face sheet, dated 05/28/25, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks), anxiety (intense, excessive, and persistent worry and fear about everyday situations), dysphagia (difficulty in swallowing), chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation), and chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period). Resident #13's face sheet reflected Resident #13's diagnosis of Bi-Polar had an on-set date of 02/25/2025. Record review of Resident #13's quarterly MDS assessment, dated 03/09/25, reflected she had a BIMS score of 00, which indicated resident's cognition was severely impaired. Resident #13 also took an antianxiety medication during the assessment window. The MDS assessment reflected Resident #13 was dependent on staff for toileting and bathing and required substantial/maximal assistance with personal hygiene. Record review of Resident #13's PASARR Level 1 Screening, dated 02/25/25, reflected that Section C Mental Illness was marked as no, which indicated Resident #13 did not have a mental illness. Record review of Resident #13's care plan dated 03/07/25 reflected Resident #13 had a mood problem r/t to diagnosis of bipolar and anxiety disorder. Goal: Resident will have improved mood state happier, calmer appearance, no s/sx of depression, (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 5 Event ID: 675899 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 675899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matagorda Nursing & Rehabilitation Center 4521 Ave F Bay City, TX 77414 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)