Failure to Refer Residents for Level II PASRR Evaluation
Summary
The facility failed to ensure that two residents, identified as Resident #38 and Resident #22, were referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination, as required. Resident #38 was admitted with a diagnosis of unspecified psychosis, and a psychiatry progress note later confirmed a diagnosis of brief psychotic disorder. However, the Level I PASRR completed by the facility staff did not document the resident's psychiatric diagnosis, incorrectly indicating that no Level II PASRR evaluation was required. Similarly, Resident #22 was admitted with diagnoses including pseudobulbar affect, delusional disorders, and unspecified psychosis. A psychiatry care plan note confirmed these diagnoses, yet the Level I PASRR also failed to document these conditions, again incorrectly stating that no Level II PASRR evaluation was necessary. During an interview, the Director of Nursing acknowledged that the PASRRs for both residents were inaccurate and needed correction.
Penalty
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A resident with COPD, bipolar disorder, PTSD, and other serious mental illnesses was admitted and care planned as meeting PASRR Level II criteria, but the facility did not complete a PASRR Level I screen until more than eight months after admission. That Level I identified multiple major mental illnesses and instructed that the case be forwarded to the state-designated authority for a PASRR Level II evaluation. At the time of survey, there was no documentation of a completed PASRR Level II, and the RNC confirmed that the facility lacked the required Level II evaluation despite policy and federal requirements that such screenings occur prior to admission and be used in assessment and care planning.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
The facility failed to resubmit required PASARR screenings when residents experienced new or worsening mental health symptoms, started psychotropic medications, had psychotropic dose changes, or when short‑term PASARR approvals expired. One resident with dementia developed aggressive behaviors and was started on Valium and buspirone without a new PASARR reflecting the new anxiety diagnosis and medications. Another resident with depression, anxiety, and bipolar disorder had a Level II PASARR with a 90‑day approval that expired and later received buspirone for anxiety, but no updated PASARR was found. A third resident with a PASARR limited to a 60‑day approval for suspected intellectual disability remained without a resubmitted screen after the approval period. A fourth resident with depression and anxiety had increased Cymbalta dosing and multiple buspirone orders without a timely new PASARR. The Social Service Director acknowledged that PASARRs should have been resubmitted for these changes and that internal responsibility for monitoring PASARR timeliness was unclear.
Surveyors found that a resident with documented PTSD, anxiety, and depression did not have these mental health conditions recorded on the PASRR Level I, and no PASRR Level II was submitted to the state agency as required. The SSD later acknowledged that the PASRR Level I should have been corrected and a Level II completed, indicating that coordination of PASRR assessments and related care planning for this resident was not properly carried out.
A resident with autistic disorder, dementia, and significant ADL dependence had PASARR Level II recommendations and a care plan indicating the need for habilitative OT services. During a PASARR IDT meeting, the LAR requested re-evaluation for OT, and new specialized OT services were marked, but facility staff did not submit the required NFSS request for OT through the Simple LTC portal within the mandated timeframe. Key staff either did not attend the PASARR meeting or were unaware of the submission deadline, resulting in the resident not receiving the PASARR-authorized OT services despite facility policy requiring coordination with PASARR.
The facility failed to request Level II PASRR evaluations for two residents after new serious mental illness conditions were identified. One resident with a prior Level I PASRR later developed nighttime hallucinations requiring antipsychotic therapy, yet no PASRR reevaluation was submitted in NC MUST. Another resident with a Level I PASRR was subsequently diagnosed with PTSD and depression and started on prazosin and sertraline, with these diagnoses reflected on the MDS, but no Level II PASRR request was made. The SW reported being responsible for Level II PASRR submissions but stated she was not always informed of new mental health diagnoses and acknowledged these omissions as oversights, which the administrator confirmed as residents being overlooked during PASRR reviews.
Failure to Obtain Required PASRR Level II Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to coordinate required PASRR evaluations for a resident with major mental illness in accordance with its own policy and federal guidance. The facility’s Resident Assessments PASRR Screening Coordination policy required that PASRR Level I and Level II screenings, when needed, be conducted prior to admission, and that Level II evaluation reports be used when conducting assessments and developing care plans. The State Operations Manual, Appendix PP, specified that a positive Level I screen requires an in-depth Level II evaluation by the state-designated authority prior to admission. Despite these requirements, the facility did not ensure that the appropriate PASRR process was completed. Resident #4 was admitted with multiple diagnoses, including COPD, Bipolar Disorder, and PTSD. The resident’s care plan documented that the resident met PASRR Level II determination secondary to serious mental illness diagnoses, including anxiety and bipolar disorder, and a long-term care stay. However, the medical record showed that a PASRR Level I screening was not completed until more than eight months after admission, and that this Level I identified major mental illnesses (depressive, anxiety, bipolar, and PTSD) and directed that the screening be forwarded to the state-designated authority for a PASRR Level II evaluation. As of the surveyor’s review, there was no documentation that a PASRR Level II evaluation had been completed, and the RNC confirmed that the facility did not have a PASRR Level II for this resident and should have had one.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Failure to Resubmit PASARR for Residents With Mental Health Changes and Psychotropic Medication Adjustments
Penalty
Summary
The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASARR) updates and resubmissions were completed when residents experienced changes in mental health status, psychotropic medication use, or when short-term approvals expired. For one resident with Alzheimer’s disease and dementia, the hospital discharge documentation did not list anxiety or psychotropic medications, and the initial Level I PASARR identified only dementia with a requirement for a Level II evaluation and resubmission if changes occurred. After admission, this resident developed significant new behaviors, including attempts to force open a fire exit door, yelling, cursing, threatening to hit staff, and physically hitting and pushing staff. In response, the physician ordered multiple psychotropic medications, including Valium and buspirone, for anxiety and agitation, but no new PASARR Level I screen reflecting the new anxiety diagnosis and psychotropic medications was found in the medical record. Another resident with major depressive disorder, anxiety disorder, and bipolar disorder had a Level I PASARR that identified Seroquel use and required a Level II evaluation. The Level II PASARR granted a 90‑day short‑term approval, with a specified end date, but there was no evidence in the clinical record that a new Level II PASARR was completed before the approval period ended. During this time, a new physician’s order was written for buspirone for anxiety, yet no PASARR documentation including this new psychotropic medication was located. A third resident, with diagnoses including mild cognitive impairment, hypertension, and type 2 diabetes, had a Level I PASARR with a 60‑day approval related to a suspected or confirmed intellectual disability, which required a new Level I screen if the resident remained beyond the approved days. The record did not contain a resubmitted PASARR after the 60‑day approval period expired. For a fourth resident with severe recurrent major depressive disorder, anxiety disorder, and chronic pain, the PASARR documented depression, anxiety, and treatment with Cymbalta. Subsequent physician orders showed an increased Cymbalta dosage and multiple changes in buspirone dosing over time, with buspirone ultimately remaining on the scheduled medication list along with Cymbalta. Despite these changes in psychotropic medication regimen, there was no evidence of a timely new PASARR screen when the new medication was started or when the regimen changed. Interviews with the Social Service Director confirmed that new PASARR submissions were expected when psychotropic medications were added, when short‑term approvals were ending, or when new mental health diagnoses were made, and acknowledged that the affected residents’ PASARRs were not resubmitted as required and that responsibility for timely PASARR submission had not been clearly established within the facility.
Failure to Complete Correct PASRR Level I and Required Level II for Resident With Mental Health Diagnoses
Penalty
Summary
Surveyors determined that the facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program by not providing a required PASRR Level II to the designated state agency for one resident. The resident was admitted with multiple diagnoses, including PTSD, anxiety, and depression. A PASRR Level I completed on 3/27/25 did not document that the resident had PTSD or an anxiety disorder, despite these diagnoses being present. During an interview on 3/18/26 at 9:34 AM, the Social Services Director (SSD) acknowledged that the resident should have had a corrected PASRR Level I completed, along with a PASRR Level II, due to the PTSD and anxiety diagnoses. This failure resulted in incomplete coordination of care and lack of appropriate documentation of interventions in the resident’s care plan, as identified through observation, policy review, and staff interviews. The deficient practice was identified for 1 of 2 residents whose records were reviewed for PASRR documentation and was based on the discrepancy between the resident’s documented mental health diagnoses and the information recorded on the PASRR Level I, as well as the absence of a PASRR Level II referral to the state agency.
Failure to Implement PASARR-Recommended Occupational Therapy Services
Penalty
Summary
The facility failed to coordinate assessments and care with the PASARR program by not incorporating the PASARR Level II recommendations for occupational therapy into a resident’s assessment, care planning, and transitions of care. The resident was an older female with autistic disorder, dementia, and a cognitive communication deficit, who required extensive to total assistance with all ADLs and had documented memory problems. Her care plan identified PASRR-positive status related to an intellectual disability and included an intervention for habilitative OT services five times per week for a defined period. A PASRR Comprehensive Service Plan meeting documented that the resident’s LAR accepted habilitation coordination and requested that the resident be re-evaluated for OT, with the PASRR form marking new specialized assessment and specialized OT services. Despite these PASARR determinations, the facility did not complete and submit the required NFSS request for OT through the Simple LTC portal within the 20-day timeframe following the PASARR IDT meeting. Portal records showed an OT assessment had been completed and was pending state review, but the necessary information was not entered in a timely manner. Interviews with the MDS coordinator, DOR, DON, and Administrator revealed that key staff either did not attend the PASARR IDT meeting, were unaware of the required timeframe, or believed the responsibility for portal submission rested with others. Staff acknowledged that, because the NFSS was not submitted within the required timeframe, the resident would not receive the PASARR-authorized OT services. The facility’s written policy stated it would coordinate assessments with the PASARR program to ensure individuals with mental disorders or intellectual disabilities received appropriate care and services, but this coordination did not occur for this resident’s OT services.
Failure to Request Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to request Level II Preadmission Screening and Resident Review (PASRR) evaluations after new serious mental illness conditions were identified in residents who previously had Level I PASRR determinations. For one resident with a Level I PASRR dated 05/06/13, the admission MDS showed no serious mental illness per the state Level II PASRR process, although active diagnoses included major depressive disorder and anxiety disorder, and the resident was receiving antidepressant medication. On 11/19/25, a NP documented that the resident was experiencing nighttime hallucinations, with staff reporting the resident was screaming and terrified at night, and Seroquel 50 mg at bedtime was initiated. A psychiatric note on 02/27/26 documented follow-up after Seroquel was increased to 100 mg, with decreased hallucinations and mood disturbance. Despite these developments, an NC MUST inquiry on 03/17/26 showed no PASRR reevaluation requests had been submitted after 11/19/25. A second resident had a Level I PASRR dated 09/19/24, with no further screening required unless a significant change suggested a mental illness diagnosis or change in treatment needs. A psychiatric progress note dated 02/06/25 documented that on 01/30/25 the resident was started on prazosin 1 mg at bedtime and sertraline 50 mg daily for nightmares and PTSD symptoms, with diagnoses of PTSD and depression. The annual MDS later reflected active diagnoses of depression (other than bipolar) and PTSD, and antidepressant use, while still indicating the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. An NC MUST inquiry on 03/17/26 confirmed no PASRR reevaluation requests had been submitted after 01/30/25. In interviews, the social worker stated she was responsible for submitting Level II PASRR requests but was not always notified of new mental illness diagnoses and acknowledged not submitting requests for these two residents as an oversight. The administrator confirmed the social worker’s responsibility for Level II PASRR requests and stated these residents were overlooked during PASRR reviews and audits.
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