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F0645
D

Failure to Complete Required PASARR Level II Evaluation for Resident with Serious Mental Illness

Pasadena, California Survey Completed on 05-05-2025

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 follow through with the Preadmission Screening and Resident Review (PASARR) process by not obtaining a required Level II evaluation for a resident with a diagnosis of schizoaffective disorder and dementia. The resident's records indicated a need for a Level II mental health evaluation after a Level I PASARR screening identified a serious mental illness. The California Department of Health Care Services was unable to complete the Level II evaluation because facility staff were unresponsive to multiple communication attempts within the required timeframe. The MDS nurse, who was responsible for PASARR screenings, was not aware that the evaluation was not completed and could not provide documentation of any follow-up actions. Interviews with facility staff revealed a lack of awareness and follow-up regarding the incomplete PASARR Level II evaluation. The MDS nurse acknowledged the importance of completing the evaluation, especially for residents with serious mental illness, but could not recall or document any follow-up. The Social Services Director stated she did not have access to the PASARR portal and was unable to verify the status of the evaluation. The Director of Nursing was also unaware that the evaluation had not been completed. The facility's policy indicated that residents identified as potentially having mental disorders should be referred for Level II screening, but this process was not followed in this case.

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