Failure to Notify State Mental Health Authority of Significant Changes in Residents' Conditions
Summary
The facility failed to notify the state mental health authority of significant changes in the mental health conditions of two residents, which is a requirement under the Preadmission Screening and Resident Review (PASARR) process. Resident #33 was admitted with several diagnoses, including major depressive disorder and a history of traumatic brain injury. Despite a new diagnosis of schizoaffective disorder in August 2023, the facility did not complete a significant change PASARR or notify the state mental health authority. Additionally, the major depressive disorder diagnosis was not included in the PASARR completed in November 2021. Similarly, Resident #2, who was admitted with multiple diagnoses including dementia and major depressive disorder, received a new diagnosis of paranoid schizophrenia in April 2022. However, the facility did not complete a new PASARR following this significant change in the resident's mental health condition. The Social Services Director confirmed that no updated PASARRs were completed for either resident following their new diagnoses, indicating a lapse in the facility's compliance with PASARR requirements.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple medical and mental health diagnoses was not reassessed for PASRR after receiving new mental health diagnoses and being prescribed additional psychotropic medications. The social worker did not complete the required reassessment due to being unaware of these changes, despite facility policy requiring coordination of PASRR assessments after significant changes.
A resident with multiple chronic conditions began receiving hospice services following a physician's order, but facility staff did not complete an updated PASARR assessment after this significant change in condition. This lapse was confirmed through medical record review and staff interview.
A resident with a history of traumatic brain injury and intact cognition was given a new diagnosis of major depressive disorder, recurrent. Following this significant change in mental health status, the facility did not complete a significant change PASARR or notify the state mental health authority, as confirmed by record review and staff interview.
The facility failed to notify the state mental health agency of significant mental health changes for three residents, affecting their PASARR documentation. One resident had multiple mental health diagnoses not updated, another had diagnoses like bipolar disorder and anxiety disorder missing from documentation, and a third had an inaccurate PASARR screening missing insomnia. Social Services confirmed the inaccuracies, and the facility's policy requiring coordination with the PASARR program was not followed.
A facility failed to update the PASARR for a resident admitted to hospice care, despite completing a significant change MDS assessment. The resident had multiple diagnoses, including hemiplegia and schizophrenia. The Social Services Director confirmed the oversight, acknowledging that the PASARR should have been updated upon hospice admission.
A facility failed to timely coordinate a level II evaluation for a resident with bipolar disorder and schizophrenia, as required by PASARR. Despite a change of condition indicating the need for further evaluation, there was no evidence of coordination with the state mental health agency for several months. The deficiency was confirmed through record reviews and staff interviews.
Failure to Reassess for PASRR After New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was reassessed for the Pre-Admission Screening and Resident Review (PASRR) following significant changes in mental health diagnoses and the initiation of new psychotropic medications. Specifically, the resident was admitted with multiple diagnoses, including hemiplegia, type II diabetes, unspecified anxiety disorder, unspecified persistent mood disorder, and chronic systolic heart failure. The medical record showed that the resident received new diagnoses of unspecified anxiety disorder and persistent mood (affective) disorder, and was prescribed several psychotropic medications, including Divalproex sodium, Ativan, and Lexapro, on multiple occasions. Despite these significant changes, there was no evidence in the medical record that a significant change PASRR assessment was completed after the new diagnoses or after the psychotropic medications were ordered. During an interview, the social worker confirmed that she had not reassessed the resident for PASRR because she was unaware of the changes in diagnoses and medications. Facility policy required the social worker to coordinate PASRR assessments and notify appropriate services if Level II services were needed, but this process was not followed in this case.
Failure to Update PASARR Assessment After Significant Change in Condition
Penalty
Summary
Facility staff failed to update the Preadmission Screening and Resident Review (PASARR) assessment for a resident with multiple diagnoses, including cerebrovascular disease, chronic obstructive pulmonary disease, neurocognitive disorder, and diabetes, after a significant change in condition. The resident was admitted and later began receiving hospice services as ordered by a physician. Despite this change, the medical record review and staff interview confirmed that the facility did not complete an updated PASARR assessment when the resident was enrolled in hospice, as required. This deficiency was identified during a review of four residents for PASARR completion, affecting one resident out of a facility census of 89.
Failure to Notify State Mental Health Authority After Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority and complete a significant change Preadmission Screening and Resident Review (PASARR) for a resident who experienced a notable change in mental health condition. The resident, who was admitted with a diagnosis of unspecified focal traumatic brain injury and was cognitively intact per a recent Minimum Data Set (MDS) assessment, received a new diagnosis of major depressive disorder, recurrent. Despite this significant change in mental health status, there was no documentation of a significant change PASARR or notification to the state mental health authority following the new diagnosis. This was confirmed through record review and staff interview, which verified that the required notification and assessment were not completed after the change in the resident's condition.
Failure to Update PASARR Documentation for Residents
Penalty
Summary
The facility failed to notify the state mental health agency of significant mental health changes for residents requiring Pre-Admission Screening and Resident Review (PASARR) updates. This deficiency affected three residents who had changes in their mental health diagnoses that were not communicated as required. Resident #3 had multiple mental health diagnoses, including bipolar disorder and major depressive disorder, which were not updated on her PASARR document. Similarly, Resident #15 had diagnoses such as bipolar disorder and anxiety disorder that were not reflected in her PASARR documentation. In both cases, there was no evidence in the progress notes to indicate that the state mental health agency had been informed of these significant changes. Resident #59 also experienced a deficiency in PASARR documentation. The resident's PASARR screening did not include the diagnosis of insomnia, despite it being a part of the resident's medical record and treatment plan. An interview with Social Services confirmed that the PASARR screening was inaccurate and had been sent to the Department of Aging without the necessary updates. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders receive appropriate care, but this was not adhered to, leading to the deficiencies noted.
Failure to Update PASARR for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Preadmission Screening and Resident Review (PASARR) for a resident following their admission to hospice care. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hypertension, congestive heart failure, unspecified dementia, and schizophrenia, had a physician's order for hospice admission dated 07/18/24. Although the facility completed a significant change Minimum Data Set (MDS) assessment due to the hospice admission, they did not update the PASARR as required. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the PASARR should have been updated on the date of the hospice admission.
Failure to Timely Coordinate Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure timely coordination with the state mental health agency for a level II evaluation for a resident with mental health diagnoses. The resident, who was admitted with bipolar disorder and schizophrenia, was found to be cognitively intact according to the Minimum Data Set (MDS) 3.0 assessment. A change of condition PASARR was completed, indicating the need for a level II evaluation. However, there was no evidence of coordination with the state mental health agency for this evaluation from the time it was required until several months later. The deficiency was identified through a review of the resident's medical records, facility policy, and staff interviews. The Social Services Assistant (SSA) acknowledged that the coordination for the level II evaluation was not initiated until months after it was required. The facility's policy states that if a level I screening indicates the presence of a mental illness or intellectual/developmental disability, the individual should be referred to the local community mental health program for a comprehensive level II screening. This process was not followed in a timely manner for the resident in question.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
