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F0645
D

Failure to Timely Resubmit and Accurately Complete PASRR Screenings

La Jolla, California Survey Completed on 04-24-2025

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

The facility failed to ensure compliance with PASRR (Preadmission Screening and Resident Review) requirements for residents with mental disorders or intellectual disabilities. For one resident with a history of bipolar disorder, schizoaffective disorder, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, the facility did not resubmit a new Level I PASRR screening after the resident remained in the facility beyond 30 days, as required. The omission was confirmed by the MDS Coordinators, who acknowledged that the process for resubmission was not followed and the required screening was not completed within the specified timeframe. Both the Director of Nursing and the Executive Director stated their expectation that the Level I be resubmitted within the required period, but this did not occur. Additionally, for another resident with diagnoses of depression and schizophrenia, the facility failed to ensure the accuracy of the Level I PASRR screening. The resident's medical record and care plan documented active diagnoses of depression and schizophrenia, but the Level I screening incorrectly indicated the absence of serious mental disorders. The MDS Coordinator admitted the screening was inaccurate and should have been reviewed for correctness. The Director of Nursing and Executive Director both stated that it was their expectation for the Level I screening to be accurate and resubmitted if found to be incorrect, but this was not done.

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