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F0644
D

Failure to Update PASRR Assessment After New Mental Illness Diagnosis

Gainesville, Georgia Survey Completed on 06-12-2025

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 submit a new Pre-admission Screening and Resident Review (PASRR) Level I Assessment after a resident received a new diagnosis of unspecified psychosis and was prescribed haloperidol for treatment. The resident, who had a history of dementia with agitation and depression, was involved in a behavioral incident where she hit another resident, leading to police notification. The original PASRR Level I Assessment completed at admission did not identify a primary diagnosis of serious mental illness. However, after the new diagnosis and initiation of antipsychotic medication, no updated PASRR was completed or submitted. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for completing and updating PASRR assessments. The Social Services Director, Admissions Director, and MDS Coordinator each indicated that they did not handle PASRR updates, and the Administrator was unsure if a new PASRR had been submitted for the resident's new diagnosis. Additionally, the facility did not have a written PASRR policy available upon request.

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