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F0644
D

Failure to Accurately Update PASARR Assessment for Resident with Mental Health Diagnoses

Loma Linda, California Survey Completed on 07-03-2025

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 update the Pre-admission Screening and Resident Review (PASARR) assessment for a resident who was admitted with diagnoses of major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Upon review, it was found that the PASARR assessment used for admission did not include the resident's diagnoses of major depressive disorder and anxiety disorder, and incorrectly indicated that the resident did not have a serious mental illness. The resident's medical records showed ongoing treatment with buspirone for anxiety and fluoxetine for depression, and these conditions were documented in the admission and social history records. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was responsible for reviewing the completion and accuracy of PASARR assessments for all new admissions. The MDS nurse acknowledged that the PASARR assessment was inaccurate and should have been revised to reflect the resident's mental health diagnoses, but this was not done. The facility's policy required all new admissions to be screened for mental disorders per the PASARR process, but the discrepancy in the resident's assessment was not identified or corrected.

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