Las Alturas de Penitas: PASRR Screening Failure - TX
The resident, identified in inspection records only as Resident #93, is described as a man who was admitted on April 10, 2026. His medical record listed schizophrenia as an active diagnosis. His cognitive assessment, completed as part of his minimum data set, placed him in the range of severe cognitive impairment. He also carried diagnoses of stage 4 chronic kidney disease, hypertension, mild neurocognitive disorder, and a seizure condition.
None of that appeared to matter when staff completed the Pre-Admission Screening and Resident Review, the federally required process meant to identify residents with mental illness and connect them to specialized services. On the PASRR form dated April 14, 2026, the section asking for evidence of mental illness was answered with a zero. No mental illness.
When inspectors interviewed Resident #93 on May 27, he said he was doing okay. He did not respond to further questions.
That same afternoon, a registered nurse at the facility, identified as RN F, told inspectors she had noticed the problem. She said the PASRR showed no mental illness, but she knew the resident had a schizophrenia diagnosis. She said she had been trying to reach the Local Mental Health Authority to find out whether he had been receiving services before he arrived. No Level II PASRR, the follow-up evaluation that would have opened the door to a formal services review, had ever been completed. "It could be an injustice to him," she said, "if he's not receiving services through the LMHA if he chose to receive them."
RN F was new to the position. The Director of Nursing told inspectors the following day that RN F was overseen by regional management and that the MDS department carried responsibility for completing resident PASRR screenings. The DON said residents needed to be evaluated and have their proper diagnoses addressed so they could receive the services they needed. She did not indicate that anything had been done to correct the record or initiate the Level II process.
The PASRR system exists specifically to prevent this. Under federal rules, any person with a mental illness seeking admission to a Medicaid-certified nursing facility must be screened before or shortly after admission. The screening is supposed to identify what specialized services the resident needs and determine which of those the state is responsible to provide. If the screening is wrong, none of that happens. The resident simply sits in the facility, their mental health needs unexamined and unaddressed.
For Resident #93, severely cognitively impaired and largely unable to communicate with inspectors, there was no way to know from the outside what services he might have wanted or needed. He could not advocate for himself. The form that was supposed to do that work for him said he had no mental illness. It had said so since April 14.
The facility's own policy, dated March 2023, states that PASRR screens are required for all individuals with mental illness regardless of payment source and must be completed within fourteen days of admission. Resident #93's screening was completed within that window. It was also wrong.
Federal inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting a small number of residents. One resident was cited.
RN F was still trying to reach the Local Mental Health Authority when inspectors arrived. Whether she had reached them, and whether Resident #93 had been connected to any services, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Alturas De Penitas from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
LAS ALTURAS DE PENITAS in PENITAS, TX was cited for violations during a health inspection on May 28, 2026.
The resident, identified in inspection records only as Resident #93, is described as a man who was admitted on April 10, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.