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F0641
E

Inaccurate MDS Coding for PASRR Status

Greensburg, Louisiana Survey Completed on 04-09-2025

Penalty

6 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the PASRR (Preadmission Screening and Resident Review) status for three residents. Record reviews showed that each of these residents had diagnoses such as Bipolar Disorder, Depression, Dementia, Schizophrenia, Paranoid Schizophrenia, and Major Depressive Disorder, and all had current Level II PASRR determinations. Despite this, their annual MDS assessments incorrectly coded Section A1500 (PASRR) as 'No,' indicating that they did not have a Level II PASRR, when in fact they did. Interviews with the Director of Nursing (DON) confirmed that the facility was unable to locate the PASRR form for one resident, but acknowledged that all three residents should have been coded as having a Level II PASRR on their MDS assessments. The care plans for these residents also documented the presence of a Level II PASRR, further highlighting the inconsistency between the clinical records and the MDS documentation.

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