Failure to Accurately Complete PASRR for Resident
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident, identified as Resident #166, out of five residents investigated for Level I PASRR. The deficiency was identified during a survey when it was found that the PASRR documentation for Resident #166 did not include any diagnosis, despite the resident having a history of mental illness. The PASRR screen decision-making section did not have any diagnosis checked, which was a significant oversight given the resident's medical history. The record review revealed that Resident #166 had an admission date with unspecified diagnoses. The Minimum Data Set (MDS) indicated that the resident was not considered by the state level II PASRR process to have a serious mental illness or intellectual disability, which was inconsistent with the resident's medication records and evaluation notes. The resident was taking medications that suggested a history of mental illness, yet this was not reflected in the PASRR documentation. Interviews with facility staff, including the Social Services Director and the Director of Care Coordination, revealed that there were discrepancies in the PASRR documentation. The Social Services Director acknowledged the discrepancies and noted that a resident review was scheduled to occur within 30 days of the evaluation to assess any changes in the patient's condition. The Director of Care Coordination stated that significant changes in a resident's condition are typically evident through behavioral changes, and the facility reviews PASRRs within 30 days for further evaluation. However, the failure to initiate a new resident review for Resident #166 earlier to include all mental illness diagnoses was a critical oversight.
Plan Of Correction
Immediate Action: The Pre Admission Screening and Resident Review for sample resident #166 was reviewed, updated, and submitted to the appropriate state agency on . Confirmation of update and receipt of determination has been obtained and was filed in residents chart. The staff member responsible received a 1:1 education on procedure for completing the Pre Admission Screening and Resident Review by Corporate Director of Social Service. Identification of Residents with potential to be affected: All residents have the potential to be affected. System Changes: The PASRR Policy was reviewed with all Social Work Staff responsible for completing PASRR Level I and requirement. All newly admitted residents will have the Pre Admission Screening and Resident Review reviewed for accuracy and resubmitted when inaccuracies are identified. Monitoring: A Pre Admission Screening and Resident Review audit for all admissions and present residents are being reviewed by the Social Work Director to ensure accurate completion. The Audit results will be submitted to the monthly Quality Assurance Performance Improvement Team for review. The audit will continue for 90 days or until the committee agrees substantial compliance is achieved. Responsible Party: Director of Social Work Corporate Director of Social Work/ Care Coordinator
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to submit Level II PASRR requests for two residents admitted with PTSD, depression, and anxiety diagnoses. Both residents had Level I PASRR screenings that did not document mental health diagnoses, while later psych notes showed active psychiatric conditions and treatment with antidepressants and anxiolytics. The SW confirmed she was responsible for PASRR re-evaluations and said the omission was an oversight.
A resident admitted with major depressive disorder had a PASARR Level I screen indicating suspected serious mental illness, but the medical record did not include a PASARR Level II screen. The SW confirmed she was responsible for obtaining PASARR screenings and stated the resident should have had a Level II screen completed but did not.
A resident with PTSD and major depressive disorder had a PASRR Level I screen that identified personality disorder and PTSD as major mental illness, but the record lacked documentation of referral for a PASRR Level II evaluation. During review, the CEO could not determine whether the screen had been sent for Level II review and stated it should have been.
Inaccurate PASRR screening for residents with mental health diagnoses: The facility failed to ensure PASRRs accurately reflected mental illness for two residents at admission. One resident had major depressive disorder, agitation, depression symptoms, and psychotropic treatment, yet the PASRR showed no mental illness. Another resident had dementia, anxiety, and cognitive impairment, but the PASRR also showed no mental illness. Staff stated PASRRs were reviewed on admission and that diagnoses not checked should be investigated or updated.
PASRR screening and re-submission were not completed as required for two residents. One resident had PTSD documented on the MDS and was later started on an antidepressant, but the PASRR did not include the mental health diagnosis and no new PASRR was submitted. Another resident had a Level II PASRR with a 180-day time limit, but the record did not show an updated PASRR determination after the approval expired.
PASARR screening was not completed appropriately for 3 residents reviewed. One resident with anxiety-related diagnoses had no Level II PASARR despite the facility’s Level I screen, another resident with major depressive disorder, anxiety, and depression had a positive Level I screen but no Level II documentation, and a third resident with schizophrenia and anxiety had no PASARR 1 or PASARR 2 completed even though the record showed a hospital discharge exemption.
Failure to Submit Level II PASRR Requests for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for two residents who were admitted with serious mental health diagnoses. One resident was admitted with PTSD, depression, and anxiety disorder, and the record showed a Level I PASRR screening that did not document mental health diagnoses. The admission MDS indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, and a psychiatric evaluation later documented ongoing treatment with sertraline and lorazepam for depression, anxiety, and PTSD. The facility could not provide documentation that a Level II PASRR request had been submitted for this resident. The second resident was admitted with PTSD, major depressive disorder, and anxiety disorder, and the Level I PASRR screening again noted a PASRR-only review with no mental health diagnoses documented. The admission MDS showed the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, while psychiatric notes documented active diagnoses of major depressive disorder, generalized anxiety disorder, PTSD, and dementia with behaviors, along with antidepressant treatment and later lorazepam for anxiety. The facility was unable to provide documentation that a Level II PASRR request had been submitted for this resident. The social worker confirmed she was responsible for submitting PASRR re-evaluation requests and stated the omission was an oversight; the administrator stated she would expect a Level II PASRR request when a resident was admitted with a Level I PASRR and mental health diagnoses.
PASARR Level II Screen Not Completed
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident reviewed for PASARR screening. The resident was admitted with diagnoses including major depressive disorder and had a quarterly MDS assessment with a BIMS score of 15, indicating cognitive intactness. The resident’s PASARR Level I Screen Summary stated that the person had a major mental disorder and that the screening result was that the resident was suspected of having a serious mental illness, but the medical record did not include a PASARR Level II screen. During interview, the Social Worker stated she was responsible for obtaining PASARR screenings, confirmed the resident did not have a PASARR Level II screen, and stated the resident should have had one completed but did not.
Failure to Obtain PASRR Level II Evaluation After Positive Mental Illness Screen
Penalty
Summary
The facility failed to ensure that a resident identified as having major mental illness received further evaluation after a positive PASRR Level I screen. Resident #8 was admitted with diagnoses including PTSD and major depressive disorder, and the PASRR Level I assessment dated 4/30/25 documented personality disorder and PTSD, both classified as major mental illness. The resident’s record did not contain documentation showing referral for a PASRR Level II evaluation. During review on 6/25/26, the CEO reviewed the PASRR Level I assessment and stated it could not be determined whether it had been sent for Level II assessment, and further stated that it should have been sent for Level II evaluation.
Inaccurate PASRR Screening for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate PASRR was completed for residents with serious mental disorder diagnoses at the time of admission for 2 of 6 residents reviewed. Resident #15 was admitted and later readmitted with diagnoses including major depressive disorder, recurrent, unspecified, and restlessness and agitation. Although the PASRR dated 5/08/2026 documented no mental illnesses or suspected mental illnesses, the resident’s psychiatric admission note dated 5/15/2026 documented an active mental health diagnosis, including major depressive disorder, recurrent, mild, and restlessness and agitation, with symptoms of depression, anxiety, insomnia, loss of energy, and diminished interest. The resident’s care plan and physician orders also reflected depression, agitation, and treatment with escitalopram and quetiapine. Resident #176 was admitted with diagnoses including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The PASRR dated 6/17/2026 documented no mental illness or suspected mental illness. However, an acute care progress note dated 6/19/2026 described the resident as a medically complex skilled nursing facility resident with encephalopathy, acute kidney failure, dementia, end stage renal disease, and dependence on renal dialysis. The note stated the resident had underlying cognitive impairment and communication limitations, was alert and oriented, and had limited speech with brief verbal responses and nonverbal gestures. During interviews, the Regional Nurse Consultant stated the Social Services Assistant was responsible for reviewing PASRRs when residents were first admitted and that the IDT reviewed them the next day to identify whether a resident might need special services or a level II PASRR. The Social Services Assistant stated she reviewed PASRRs on admission and would look for diagnoses that might trigger special services or additional review, and if a diagnosis was not checked she would investigate whether there was a history of the condition, whether it was active, or whether the resident was being treated. The ADON stated that if a resident was admitted with a diagnosis of mental illness and it was not on the PASRR, the PASRR should have been updated.
PASRR Screening and Re-Submission Failures
Penalty
Summary
The facility failed to refer a resident with a negative Level I PASRR result and an identified mental disorder to the appropriate state-designated authority for Level II PASRR evaluation and determination. Resident #3’s MDS documented a BIMS score of 14 and a diagnosis of PTSD on admission, but the PASRR screening notice completed before admission did not list PTSD under the mental health diagnoses section. The resident was later started on mirtazapine, an antidepressant, and the Administrator stated the facility did not currently have anyone assigned to do PASRR review or submission and acknowledged that the PTSD diagnosis and antidepressant medication should have been included on the PASRR or a new PASRR should have been submitted. The facility also failed to re-submit a Level II PASRR for Resident #14 after the 180-day time-limited approval expired. Resident #14’s quarterly MDS showed a BIMS score of 15, diagnoses of depression and bipolar disorder, and extensive assistance needs with ADLs and mobility. The care plan included the resident’s Level II PASRR and the 180-day approval, and the Notice of PASRR Level II Outcome showed the approval was limited to 180 days. The EHR miscellaneous tab did not include an updated Level I PASRR determination after the time-limited approval ended, and the Administrator stated the resident PASRRs were not up-to-date.
PASARR Screening Not Completed for Residents With Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed appropriately for 3 of 5 residents reviewed. The facility did not complete a Level II PASARR for R6, who was admitted with diagnoses including adjustment disorder with anxiety and generalized anxiety disorder, and whose Level I PASARR indicated “No” to a major mental disorder. The nursing home administrator told surveyors that the facility did not have a Level II PASARR for R6 and that it should have been done. The facility also did not complete a Level II PASARR for R7, who was admitted with diagnoses including major depressive disorder, anxiety disorder, and depression. Surveyors reviewed R7’s Level I PASARR, which indicated “Yes” to whether the person had a major mental disorder, but no Level II documentation was available. For R27, who was admitted with diagnoses including schizophrenia and anxiety disorder and was prescribed medications to treat symptoms of schizophrenia and anxiety, no PASARR 1 or PASARR 2 was completed. The Level I PASARR in the record was marked as a hospital discharge exemption with a 30-day maximum, and the nursing home administrator acknowledged that a PASARR should have been completed.
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