Failure to Complete PASRR Evaluations for Residents
Summary
The facility failed to accurately complete and ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) for two residents, which is a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions. For Resident 72, the Level I PASRR did not reflect his diagnosis of autism or his use of psychotropic medications, resulting in a Level II PASRR never being completed. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the PASRR Level I screening was filled out inaccurately, impacting Resident 72's ability to qualify for a Level II evaluation and subsequent specialized services. Resident 72 was admitted with multiple diagnoses, including autistic disorder, anxiety disorder, and depression. Despite these conditions, the PASRR Level I screening incorrectly marked 'no' for autism and did not list his anxiety disorder or mood disturbance. The DON stated that had the PASRR been completed accurately, Resident 72 could have qualified for programs related to his behaviors and autism diagnosis. The failure to complete the PASRR process potentially delayed necessary services for Resident 72, who exhibited behaviors such as mood lability and crawling on the floor, which were temporarily managed with medications. For Resident 60, a positive Level I PASRR screening indicated the need for a Level II evaluation, which was not completed due to the resident being in transmission-based precautions for a medical illness. The facility's Admissions Coordinator confirmed that the PASRR Level II was not completed and that nursing staff were responsible for requesting a new PASRR screen once the resident's medical condition improved. The DON confirmed that the facility policy was not followed, resulting in a failure to complete the necessary PASRR Level II evaluation for Resident 60, who was admitted with diagnoses including bipolar disorder and major depressive disorder.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident admitted with an active diagnosis of bipolar disorder had only a Level I PASRR completed prior to admission, and the facility did not request a required Level II PASRR evaluation. The resident’s MDS assessments documented severe cognitive impairment and an active bipolar disorder diagnosis, with ongoing treatment using mirtazapine and Lamictal and a care plan addressing depression and bipolar disorder. The SW acknowledged knowing about the bipolar diagnosis but did not submit a Level II PASRR referral, believing the existing Level I PASRR was sufficient, while the Administrator recognized that Level II evaluations are important for residents who meet criteria.
The facility failed to correctly complete a PASARR Level I screening for a resident with documented chronic PTSD and anxiety disorders, as required by facility policy. The resident’s Level I screenings did not include these mental health diagnoses, which should have triggered a PASARR Level II evaluation by the state-designated authority prior to admission. Review of the medical record showed that, despite the documented PTSD diagnosis, there was no evidence that a Level II PASARR had been completed by the time of surveyor review, indicating that the required in-depth evaluation and determination letter were not obtained as mandated.
A resident admitted with documented diagnoses of dementia, anxiety disorder, major depressive disorder, and bipolar disorder, and receiving antianxiety medication, did not have a Level II PASRR evaluation requested despite meeting criteria for serious mental illness. The PASRR Level I screen omitted major depressive disorder and bipolar disorder, and the quarterly MDS indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. The Admission Coordinator lacked access to the NC MUST system and relied on the hospital and Social Work Assistant for PASRR information, while the Social Work Assistant did not verify diagnoses before providing PASRR determination letters and was not notified by the clinical team to request a Level II evaluation. The facility could not produce documentation of any Level II PASRR request for this resident.
A resident was admitted under a 30-day PASARR Level 1 exemption based on a physician’s certification that the stay would be less than 30 days following an acute hospitalization. The exemption form stated that if the stay exceeded 30 days, another Level 1 PASARR screening for SMI and IDD/DD or a related condition must be completed and submitted to the Department of Mental Health. Record review showed no evidence that a Level 1 PASARR was completed prior to admission and no subsequent screening after the 30-day period, even though the resident, who had diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and insomnia, continued to reside in the facility. The DON confirmed in interview that the PASARR screening had not been updated since the initial 30-day period.
A resident with major depressive disorder, generalized anxiety disorder, and PTSD was admitted with a short‑term Level II PASRR approval that had a defined expiration date. The admission MDS showed the resident had not been evaluated and determined to have a serious mental illness, intellectual disability, or related condition under a current Level II PASRR. Facility records contained no evidence that staff submitted a referral to obtain a new Level II PASRR evaluation before the prior approval expired. In interviews, the SW acknowledged that the Level II PASRR had expired without renewal due to an oversight, and the Administrator stated that PASRR evaluations were expected to be monitored and updated before expiration.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Obtain Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The deficiency involves the facility’s failure to obtain a Level II PASRR evaluation for a resident admitted with an active diagnosis of bipolar disorder. A Level I PASRR was completed prior to admission, dated 03/20/18, and the resident was admitted with diagnoses including bipolar disorder. Review of the medical record showed no evidence that a Level II PASRR evaluation had ever been completed. The admission MDS documented an active diagnosis of bipolar disorder and indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. A subsequent quarterly MDS showed the resident was severely cognitively impaired, had no behaviors or signs of depression, but continued to have an active diagnosis of bipolar disorder and was receiving anticonvulsant and antidepressant medications daily. Physician orders confirmed ongoing treatment with mirtazapine 15 mg by mouth at bedtime for depression and appetite, and Lamictal 25 mg by mouth daily as a mood stabilizer for bipolar disorder. The active care plan included a focus area for antidepressant medications with indications of depression and bipolar disorder, with a goal for the resident to remain free from side effects and interventions to administer medications as ordered and monitor for adverse effects. During interview, the Social Worker stated that because a Level I PASRR had already been completed prior to admission, she did not submit a referral for a Level II PASRR evaluation and was not aware that she was required to do so, despite knowing the resident had a bipolar disorder diagnosis. In a separate interview, the Administrator acknowledged the importance of completing Level II PASRR evaluations for residents who meet criteria so they can receive needed services.
Failure to Accurately Complete PASARR Level I and Initiate Required Level II Evaluation
Penalty
Summary
The facility failed to ensure that a Level I Pre-admission Screening and Resident Review (PASARR I) was completed correctly for one resident, resulting in an omission of documented mental health diagnoses that should have triggered a Level II PASARR. Facility policy dated 8/29/25 required that a Level I PASRR be completed on potential admissions prior to admission, with a positive Level I screen leading to an in-depth Level II evaluation by the state-designated authority and a determination letter obtained prior to admission. The resident, who was initially admitted and later readmitted with multiple diagnoses including chronic post-traumatic stress disorder (PTSD) and joint replacement surgery aftercare, had Level I PASRR screenings dated 3/3/26 and 3/13/26 that did not document his PTSD and anxiety disorders. The resident’s medical record on 3/3/26 showed a medical diagnosis of chronic PTSD, yet as of 3/30/26 at 12:00 PM there was no documentation that a Level II PASARR had been completed, despite these qualifying mental health conditions. Staff later acknowledged that a Level II PASARR had only just been completed and sent for review, confirming that the required Level II process had not been initiated in a timely manner based on the resident’s documented diagnoses. This failure created the potential for harm if residents required, but did not receive, specialized services for mental health while residing in the facility.
Failure to Request Level II PASRR for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident with serious mental health disorders. Documentation showed the resident had a Level I PASRR determination with no expiration date, and the North Carolina PASRR Level I screen did not list major depressive disorder or bipolar disorder. However, the resident was admitted with diagnoses including metabolic encephalopathy, vascular dementia, anxiety disorder, major depressive disorder, and bipolar disorder. A quarterly MDS assessment documented active psychiatric/mood disorder diagnoses of non-Alzheimer’s dementia, anxiety disorder, depression (other than bipolar), and bipolar disorder, and indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. The resident was also receiving antianxiety medication during the assessment period. Further record review and interviews revealed that psychiatry had been consulted to review the resident’s psychotropic medications, confirming diagnoses of dementia, insomnia, depression, anxiety, and bipolar disorder, with continuation of buspirone ordered twice daily. The facility was unable to provide documentation that a Level II PASRR evaluation request had been submitted for this resident. The Admission Coordinator stated he did not have access to the NC MUST system and relied on the hospital to initiate PASRR screenings and on the Social Work Assistant to provide PASRR determination letters. The Social Work Assistant reported she did not verify new residents’ diagnoses before providing the PASRR Determination Notification letter and had not been informed by the clinical team to request a Level II PASRR evaluation for this resident. The Administrator confirmed that residents were discussed in daily clinical meetings and acknowledged that a Level II PASRR request should have been submitted for this resident based on the mental health diagnoses.
Failure to Complete Required PASARR Screening After 30-Day Exemption
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASARR (Pre-admission Screening and Resident Review) was completed for a resident who was admitted under a 30-day exemption and remained in the facility beyond that period. Record review showed that the resident had a PASARR Level 1 exception form signed by a physician, certifying that the resident was being admitted directly from an acute hospitalization and was likely to require less than 30 days in the nursing facility, qualifying for the short-stay exemption. The form specified that if the stay exceeded 30 days, another Level 1 screening for serious mental illness and intellectual/developmental disability and/or a related condition must be completed by the admitting nursing home and submitted to the Department of Mental Health. There was no evidence in the resident’s medical record that a Level 1 PASARR was completed prior to admission, and no evidence of any further PASARR screening after the 30-day exemption period was exceeded, despite the resident continuing to reside in the facility. The resident’s diagnoses included Post Traumatic Stress Disorder, unspecified, Adjustment Disorder with mixed anxiety and depressed mood, and insomnia. During an interview, the DON confirmed that the PASARR screening had not been updated since the initial 30-day period while the resident remained in the facility.
Failure to Renew Expired Level II PASRR Authorization
Penalty
Summary
The facility failed to obtain a new Level II Preadmission Screening and Resident Review (PASRR) evaluation after the expiration of a short‑term approval for nursing home placement for one resident. The resident was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and post‑traumatic stress disorder, and the admission MDS indicated the resident had not been evaluated by a Level II PASRR and determined to have a serious mental illness, intellectual disability, or related condition. Record review showed the resident was admitted with a Level II PASRR for short‑term admission that had a specific issuance and expiration date, but there was no documentation that the facility submitted a referral for another Level II PASRR evaluation to extend approval beyond the expiration date. In interviews, the Social Worker confirmed that the resident’s Level II PASRR for short‑term admission had expired and acknowledged that she had not submitted a request for another Level II PASRR evaluation, describing the lapse as an oversight that had fallen through the cracks and stating that a new evaluation should have been requested before the temporary one expired. The Administrator stated that she expected PASRR evaluations to be monitored and kept up to date and acknowledged that a review for this resident should have been requested before the expiration date.
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