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F0645
D

Failure to Complete Required PASARR Level II Evaluation

Pasadena, California Survey Completed on 06-05-2025

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 ensure that a required Preadmission Screening and Resident Review (PASARR) Level II evaluation was completed for a resident with diagnoses including anxiety disorder, unspecified psychosis, and end stage renal disease. The resident's admission record and Minimum Data Set (MDS) indicated moderate cognitive impairment and the use of antipsychotic and antianxiety medications. Documentation showed that a PASARR Level I screening determined a Level II Mental Health Evaluation was necessary, and the facility was notified that an evaluator would contact them to schedule the assessment. However, the Level II evaluation was not completed because facility staff were unresponsive to multiple attempts by the evaluator to arrange the assessment within the required timeframe. As a result, the case was closed, and the facility was informed that a new Level I screening would be needed to reopen the case. The staff member responsible for PASARR follow-ups was unaware that the case had been closed and did not submit a new screening, contrary to facility policy, which requires completion of the PASARR Level II prior to admission and incorporation of its recommendations into the resident's care plan.

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