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F0645
D

Failure to Accurately Complete PASRR for Residents with Mental Health Diagnoses

Lake City, Florida Survey Completed on 07-31-2025

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 the Preadmission Screening and Resident Review (PASRR) process was accurately completed for two residents. For one resident with a history of residual schizophrenia, unspecified mood disorder, adjustment disorder, major depressive disorder, generalized anxiety disorder, and paranoid schizophrenia, the PASRR did not reflect persistent mood disorder or suspected mental illness in the relevant section. This omission was identified despite the resident's psychiatric notes and Minimum Data Set (MDS) assessment indicating active diagnoses of mood and mental health disorders. The Director of Nursing (DON) acknowledged that the PASRR needed updating and was unaware that additional diagnoses could be added in the specified section. Similarly, another resident with diagnoses including brief psychotic disorder, major depressive disorder, other specified persistent mood disorders, and generalized anxiety disorder had a PASRR that did not list these mental health conditions under the mental illness or suspected mental illness section. The resident's psychiatric notes and MDS assessment documented these active diagnoses, but they were not reflected in the PASRR. The DON confirmed that the PASRR for this resident also required updating to include the missing diagnoses.

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