Las Alturas De Penitas

Based on interview and record review, the facility failed to ensure all pre-admission screening and resident review (PASRR) Level 1 residents with mental illness were provided with an accurate PASRR Level 1 for 1 (Resident #93) of 3 residents reviewed for PASRR screening. Resident #93 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness.This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning.

Findings were:

Record review of Resident #93's admission Record dated 05/28/26 reflected a [AGE] year-old male with an admission date of 04/10/26 and diagnoses of Essential (Primary) Hypertension (high blood pressure), Mild neurocognitive Disorder Due to Known Physiological Condition Without Behavioral Disturbance (decline in memory or thinking skills), Chronic Kidney Disease Stage 4 (severe kidney damage) and Other Seizures (uncontrolled surge of electrical activity in the brain).

Record review of Resident #93's admission MDS dated [DATE] reflected a BIMS score of 05 which indicated severe cognitive impairment.

Additionally, under Section I Resident #93 had an active diagnosis of Schizophrenia.

Record review of Resident #93's PASRR dated 04/14/26 reflected under section C0100 Evidence of Mental Illness was answered as 0 indicting the resident did not have a mental illness.

During an interview on 05/27/26 at 9:32 a.m. Resident #93 said he was doing ok. Resident #93 was not responsive to any other questions at the time of the interview.

During an interview on 05/27/26 at 3:47 p.m. RN F said Resident #93's PASRR indicated he did not have a mental illness.

She said he had a diagnosis of Schizophrenia and she was trying to communicate with the Local Mental Health Authority to find out if he was receiving services before being admitted to the facility.

She said there was no PASRR Level II done.

She said it could be an injustice to him if he's not receiving services through the LMHA if he chose to receive them.

During an interview on 05/28/26 at 4:02 p.m., the DON said that MDS is responsible for completing resident PASRR's.

She said RN F was new to the position and was overseen by regional management.

The DON said that residents needed to be evaluated and have their proper diagnoses addressed so they could receive services that were needed.

Record review of the facility's Comprehensive Assessments Revised Date March 2023, revealed; Types of AssessmentsThe community conducts frequent and different types of assessments, depending on the resident's condition and need.

The community will conduct the following types of assessments during its relationship with the resident:-Preadmission screening and resident review (PASRR) screen is required of all individuals with mental illness (MI) or mental retardation (MR), regardless of the applicant's source of payment.

The screen lists the specialized services that are required and identifies the services the state is responsible to provide.

The community is responsible for providing the other needed services.

These screenings are providedWithin fourteen days of the resident's admission to the community

745000 05/28/2026

Las Alturas DE Penitas 414 Liberty Blvd.

Penitas, TX 78576

5LPM. LVN A was observed adjusting the level but the flow meter ball (a ball that provides a visual

been working properly. LVN A stated Resident #69 was checked every 2 hours or sooner. LVN A

stated it was important to continuously check on Resident #69 because she was unable to use the call light button. LVN A stated not checking on Resident #69 often could lead to not catching Resident #69 in respiratory distress. LVN A stated that she had checked the oxygen level on the oxygen concentrator machine at the start of her shift. LVN A stated she had raised the level to 5LPM and thought it had stayed there. LVN A stated she had not noticed the flow meter ball was not working properly. LVN A stated it was important for the oxygen concentrator to work properly because ensured Resident #69 was getting the correct level of oxygen to prevent going into respiratory distress or shortness of breath. LVN A stated that the concentrator machine was faulty and would be changed out. LVN A confirmed the date on the humidifier bottle was 05/18/26. LVN A stated that the humidifier bottle along with all the oxygen tubing should be changed every Sunday during the night shift. LVN A was observed looking at the dates on the oxygen tubing and all the dates indicated, 05/24/26. LVN A stated, It looks like all the tubing was changed except the humidifier bottle. LVN A stated it was important for the tubing and humidifier bottle to be changed as ordered because it prevented germs and infection.In an interview on 05/26/26 at 3:28pm CNA C stated she was the CNA for the hall where Resident #69 was in. CNA C stated she was aware Resident #69 was on continuous oxygen. CNA C stated she started her shift at 2:00pm but had not yet checked on Resident #69. CNA C stated it was important to check on residents that could not use their call lights more frequently than 2 hours because they could be in a type of distress, and no one would know. CNA C stated she had received in-services (teachings) on how to care for residents on oxygen.In an interview on 05/26/26 at 5:01pm, the DON stated that the nurses were responsible for checking that the oxygen tubing was connected properly to Resident #69.

The DON stated that the nurses were to follow oxygen settings in physician's orders.

The DON stated that the nurse should also have checked that the concentrator machine was also working properly.

The DON confirmed that the night shift nurse on Sunday was responsible for changing the oxygen tubing along with the humidifier bottle.

The DON stated it was important for the humidifier bottle to be changed because it would prevent infections and changes in care.

The DON stated the nurses received training on how to care for a trach patient quarterly and annually.

The DON stated the nurses were ultimately in charge of assessing residents with trachs.In an interview on 05/28/26 at 11:31am, LVN B stated he worked the night shift of Sunday, 05/24/26 and was the nurse for Resident #69. LVN B stated he was aware the humidifier bottle had to be changed. LVN B stated that when he gathered all the supplies for changing the oxygen tubing, he must have forgotten to get the humidifier bottle. LVN B stated it was important to change the humidifier bottle to prevent bacteria from building up and to prevent infection.

Record review of the facility's policy titled Tracheostomy Management with a revised date of January 2023 revealed, Guidelines: 7.

Assess the residents need for oxygen per physician's orders and have available bedside, setup with appropriated tubing.

Record review of the facility's policy titled Oxygen Administration with a revised date of January 2023 revealed, Procedure 4.

Assess the resident's condition. 5.

Monitor the resident's response to oxygen therapy.

745000 05/28/2026

Las Alturas DE Penitas 414 Liberty Blvd.

Penitas, TX 78576

which manager was assigned to check Resident #13 or Resident #43.

The DON said that a resident

the manager assigned to each resident room. He said they were training new management staff and

them.

The ADM said he didn't know if anything could have happened if Resident #13 or Resident #43 had eaten expired food but said nothing had happened.

Record review of the facility's policy titled Food Storage dated 01/01/26 revealed; Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.2.

Refrigerators. d.

Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.