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F0644
E

Failure to Complete and Resubmit PASARR Screenings for Residents with Mental Health Diagnoses

Los Angeles, 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 complete and resubmit the Preadmission Screening and Resident Review (PASARR) Level I screening and refer for a Level II evaluation when indicated for two residents. For one resident, the admission record showed diagnoses including metabolic encephalopathy, dysphagia, and dementia, with a psychiatric evaluation confirming an anxiety disorder. The resident was prescribed Lorazepam, a psychotropic medication, for anxiety. Despite these findings, the PASARR Level I completed by the transferring hospital did not reflect the mental health diagnosis or psychotropic medication use, and the facility did not resubmit a new PASARR Level I to indicate the updated diagnosis or refer for a Level II evaluation as required. Another resident was admitted with diagnoses of schizophrenia and major depressive disorder. The PASARR Level I application for this resident incorrectly indicated that there was no mental health disorder, and therefore, a Level II PASARR was not initiated. The DON acknowledged that the PASARR should have been resubmitted to reflect the accurate diagnoses, but this was not done. The DON also noted that PASARRs are to be completed before or within 24 hours of admission, but she had not been given access to process them. Facility policy and the PASRR reference manual require prompt notification and re-evaluation by the state mental health authority if there is a significant change in a resident's mental condition or if a mental illness is identified. In both cases, the facility did not comply with these requirements, resulting in the failure to ensure appropriate assessment and referral for specialized mental health services for the affected residents.

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