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F0644
D

Failure to Update PASARR Evaluations After New Mental Health Diagnoses

Orlando, Florida Survey Completed on 06-20-2025

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 and coordinate the Preadmission Screening and Resident Review (PASARR) Level I and Level II evaluations for residents who had new or existing major mental disorder diagnoses. One resident, who had been admitted with diagnoses including dementia, epilepsy, depression, anxiety, and psychotic disorder, was noted during a psychologist session to have a depressed mood and feelings of being overwhelmed. Despite these findings and changes in mental health status, there was no evidence in the medical record that the Level I PASARR had been updated until prompted by surveyors, with the most recent update occurring only after the issue was identified. Another resident, with a history of adjustment disorder, anxiety disorder, bipolar disorder, schizophrenia, and dementia, exhibited behaviors such as verbal abuse, combativeness, and catatonia. The resident's PASARR documentation did not reflect new diagnoses of schizophrenia and adjustment disorder, and only listed bipolar disorder. The Social Services Director acknowledged responsibility for updating PASARR forms and was aware that the resident should have been re-screened after the new diagnoses were added, but this was not done. The facility's policy required PASARR reviews prior to admission and upon new diagnoses, but these procedures were not followed for the residents in question.

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