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F0644
D

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

Santa Monica, California Survey Completed on 06-27-2025

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 federally required Preadmission Screening and Resident Review (PASARR) process for one resident. Specifically, after the resident was admitted and readmitted with diagnoses including schizophrenia, major depressive disorder, and diabetes, the PASARR Level I screening indicated a positive result for serious mental illness and required a Level II evaluation. However, the PASARR Level II evaluation was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. The Director of Nursing confirmed that the Level II evaluation was not completed and acknowledged that the facility did not follow up as required. The resident's records showed cognitive intactness and a need for supervision with activities of daily living. The facility's policy required all new admissions and readmissions to be screened for mental disorders and for the interdisciplinary team to determine if the facility could meet the resident's needs as outlined in the evaluation. The failure to complete the PASARR Level II evaluation meant that the facility did not fully assess whether it could meet the resident's mental health needs as required by regulation.

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