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F0644
D

Failure to Initiate PASARR Level II Referrals After New Mental Health Diagnoses

Orlando, Florida Survey Completed on 09-11-2025

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 appropriate referrals for Preadmission Screening and Resident Review (PASARR) Level II evaluations were made for two residents after new diagnoses of serious mental illness were identified. For one resident, the most recent Level I PASARR assessment did not indicate a diagnosis or suspicion of serious mental illness or intellectual disability, and no Level II evaluation was initiated, despite the resident having a diagnosis of PTSD documented in the facility's records. For another resident, a Level I PASARR was completed prior to the resident receiving new diagnoses of bipolar disorder and major depressive disorder, and there was no evidence that a Level II PASARR evaluation was conducted following these diagnoses. The Director of Nursing confirmed that Level II PASARR screenings should have been completed for both residents after the new diagnoses were made.

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