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F0645
D

Failure to Complete Required PASARR Reassessment After 30 Days

Duluth, Minnesota Survey Completed on 05-02-2025

Penalty

No penalty information released
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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

A deficiency occurred when the facility failed to ensure a required Level II Pre-Admission Screening and Resident Review (PASARR) reassessment was conducted, documented, and retained for a resident with multiple mental health diagnoses. The resident, who had severely impaired cognition and required substantial assistance with most activities of daily living, was admitted with diagnoses including dementia with agitation, delusional disorder, bipolar disorder, depression, and schizophrenia. The initial PASARR Level II assessment approved admission for post-hospital rehabilitative services for 30 days, with instructions that further assessment and service plan changes must be documented if the resident's stay exceeded 30 days or if there was a change in condition. Despite these requirements, the facility did not complete or document a PASARR reassessment after the resident remained in the facility beyond the approved 30-day period. Interviews with the admissions clerk, social services director, and director of nursing revealed that none were aware of the 30-day limitation on the Level II assessment or the need to notify the appropriate agency for reassessment. As a result, the resident's mental health needs may not have been appropriately addressed or provided for during their extended stay.

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