Failure to Conduct Accurate PASRR Screening for Resident
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) for a resident with a diagnosis of Undifferentiated Schizophrenia and mild intellectual disabilities. Upon review of the resident's electronic medical record (EMR), it was found that the admitting and current diagnosis included these conditions. However, the Comprehensive Social Assessment did not reflect these diagnoses, and the assessments were signed by the Social Services Director (SSD) with a note indicating no history of mental illness. The resident's EMR lacked documentation of a Level I or Level II PASRR. The SSD provided a Level I PASRR completed by the hospital, which inaccurately marked 'No' for the presence of a serious mental illness or intellectual disability. This error resulted in the absence of a Level II screening for specialized services. The SSD admitted to being unaware of the resident's mild intellectual disability diagnosis and stated that the facility followed a document titled 'Best Practice for PASRR' as they did not have a specific policy. The document indicated that PASRR status should be reviewed for all new admissions, and the SSD should maintain an active list of PASRR patients.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility staff did not complete required PASARR screenings prior to admission for two residents with significant mental health diagnoses, including schizophrenia, bipolar disorder, and substance abuse. In both cases, PASARR documentation was either missing, delayed, or incorrectly coded, and did not reflect the residents' psychiatric conditions or trigger further review as required.
A resident with bipolar and major depressive disorder was readmitted without a completed PASARR Level I assessment. The absence of this required screening was confirmed through record review and staff interviews, with facility staff acknowledging the oversight and lack of identification at admission.
Facility staff did not complete Level I PASARR screenings for two residents with significant mental health diagnoses, despite facility policy requiring such screenings prior to admission. Both residents' records lacked documentation of the required screening, and staff interviews revealed confusion and lack of awareness regarding responsibility for PASARR completion.
Facility staff did not fully complete required PASRR Level I forms for several residents, leaving sub-questions unanswered and omitting key information regarding mental illness and related conditions. In one case, a resident with multiple neurocognitive and mood disorder diagnoses had an incomplete screening and lacked documentation of a Level II assessment, contrary to facility policy.
Facility staff did not ensure a Level I PASARR screening was completed for a resident admitted from another facility. The required screening was missing from the clinical record, and staff interviews confirmed that the admissions process failed to identify or complete the PASARR as required by facility policy.
Facility staff did not complete required PASARR screenings prior to admission for four residents with mental health or intellectual disability diagnoses. For each affected resident, no PASARR documentation was found in the clinical record, despite the presence of relevant diagnoses and ongoing psychotropic medication use. Staff interviews and policy review confirmed that PASARR screenings were not conducted as required before admission.
Failure to Complete PASARR Prior to Admission for Residents with Mental Illness
Penalty
Summary
Facility staff failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for two residents with significant mental health diagnoses. For one resident, who was admitted with schizophrenia, bipolar disorder, mood disorder, and anxiety disorder, the PASARR I was not completed until a year after admission and was incorrectly coded, failing to identify the resident's serious mental illness. Despite ongoing psychotropic medication use, psychiatric follow-up, and documented behavioral issues such as aggression and abuse, the PASARR II was never triggered or completed as required. All relevant deficits and behaviors were well documented in the clinical record at the time. For another resident admitted with bipolar disorder, metabolic encephalopathy, psychoactive substance abuse, and seizures, no PASARR was found to have been completed prior to admission. The only PASARR in the record was dated after admission and did not document the psychiatric diagnosis. Facility staff confirmed that no PASARR had been completed prior to admission, and the Director of Nursing acknowledged that the screening should have been done to document the listed diagnoses.
Failure to Complete PASARR Level I Assessment on Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment for one resident who was readmitted with diagnoses of bipolar and major depressive disorder. Record review showed that there was no PASARR Level I assessment present in either the electronic medical record or the hard chart for this resident. During interviews, the Director of Social Services acknowledged not identifying the missing PASARR Level I at admission, and the Administrator confirmed that it was not completed at the time of admission. The Director of Nursing stated that the admissions director was expected to identify when a PASARR was missing and notify management, but this did not occur in this case. No additional information was provided prior to survey exit.
Failure to Complete Required PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
Facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) was completed for two residents with significant mental health diagnoses. One resident had diagnoses including cerebral infarction, metabolic encephalopathy, convulsions, unspecified psychosis, major depressive disorder, and generalized anxiety disorder, and was assessed as moderately cognitively impaired with delusions and wandering behavior. Despite residing in the facility for approximately five months, no Level I PASARR was found in the clinical record, and staff interviews confirmed that the screening had not been completed. The facility policy required all applicants to be screened for serious mental disorders or intellectual disabilities prior to admission, and for records of the pre-screening to be maintained in the resident's medical record. However, staff were unclear about their responsibilities regarding PASARR completion, with the social worker and admissions coordinator both stating they had not been instructed to complete the screenings. A second resident with diagnoses including suicidal ideations, major depressive disorder, and bipolar disorder with psychotic features also did not have a Level I PASARR in their clinical record. The resident was cognitively intact according to the most recent assessment. Staff interviews revealed a lack of awareness and training regarding the facility's policy on PASARR responsibilities, with both the social worker and admissions director stating they had never completed or been told to complete Level I PASARRs. The facility's policy designated the social services director as responsible for tracking PASARR status, but the social worker was unaware of this policy. No further information or documentation regarding PASARR completion was provided to the survey team prior to the exit conference.
Incomplete PASRR Level I Documentation for Multiple Residents
Penalty
Summary
Facility staff failed to properly complete the Preadmission Screening and Resident Review (PASRR) Level I forms for multiple residents, as required by document guidance. For two residents, the main questions in sections regarding serious mental illness and related conditions were answered 'No' without completing the required sub-questions. The social worker confirmed that these sub-questions were left blank when the main answer was 'No,' and stated she would have marked 'Yes' if appropriate, but did not complete the sub-questions otherwise. This incomplete documentation was identified during record review and confirmed in staff interviews. Additionally, for another resident with multiple diagnoses including Alzheimer's disease, seizure disorder, and mood disorders, the PASRR Level I screening was found to be incomplete, with a key question regarding the need for a Level II assessment left blank. There was also no Level II PASRR in the resident's record, despite policy indicating that such information should be maintained. These deficiencies were discussed with facility leadership during the survey process.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
Facility staff failed to implement PASARR (Preadmission Screening and Resident Review) requirements for one resident. Specifically, the clinical record review for this resident did not contain evidence of a completed Level I PASARR screening upon admission. The resident was admitted from a sister facility, and the omission was not identified or rectified prior to or at the time of admission. During interviews, the director of social services confirmed that all residents should have a Level I PASARR completed, and that the admissions department is responsible for ensuring this is done before admission. If not completed, the director of social services would typically complete it. However, in this case, the process was not followed, and the required screening was not present in the resident's record. Facility policy also specifies the steps for ensuring PASARR completion, but these were not adhered to for this resident.
Failure to Complete PASARR Screenings Prior to Admission
Penalty
Summary
Facility staff failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for four residents with mental health or intellectual disability diagnoses. For one resident with bipolar disorder, anxiety, and dementia, no PASARR documentation was found in the electronic health record, and the only available document was an incomplete and outdated PASARR II embedded in a Medicaid Assisted Living Annual Reassessment. The facility had experienced frequent turnover in the social worker position, resulting in a lack of oversight for preadmission screenings. Another resident with bipolar disorder and other medical conditions was admitted without a PASARR Level I being completed prior to admission from an acute care hospital. The resident was receiving psychotropic medications, and staff interviews confirmed that no PASARR documentation was found in the clinical record. The facility's policy required PASARR screenings to be completed and documented prior to admission, but this was not followed. Two additional residents, one with PTSD, major depressive disorder, and mood disorder, and another with schizoaffective disorder and moderate cognitive impairment, were also admitted without PASARR Level I screenings. Staff interviews and record reviews confirmed that no PASARR documentation was present for these residents, and staff acknowledged that the screenings should have been completed prior to admission. The deficiency was identified through observation, clinical record review, and staff interviews.
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.
