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F0645
D

Failure to Complete Required PASARR Screenings for Residents with Mental Health Diagnoses

Minneapolis, Minnesota Survey Completed on 08-15-2025

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 required Level I Pre-admission Screening (PAS) and, when indicated, Level II Pre-admission Screening and Resident Review (PASARR) were completed for three out of four residents reviewed for PAS. For one resident with diagnoses including schizophrenia, post-traumatic stress disorder, and a psychotic disorder, the medical record lacked evidence of a final PAS determination, and the director of admissions was unable to provide documentation of attempts to obtain it. The director of admissions and the director of social services gave conflicting accounts regarding responsibility for obtaining the final PAS, and no documentation was found in the resident's record. Another resident with major depressive disorder with severe psychotic symptoms, post-traumatic stress disorder, and generalized anxiety disorder also lacked evidence of a final PAS determination in the medical record. The director of admissions and the social worker director both confirmed the absence of this documentation. For a third resident with multiple psychiatric diagnoses, including anxiety, major depressive disorder, bipolar disorder, post-traumatic stress disorder, schizophrenia, and traumatic brain injury, there was no evidence that a Level I PAS or, if needed, a Level II PASARR was completed prior to admission. The director of admissions confirmed that the PAS was missed due to a new admission coordinator being trained. The facility's policy required Level I screening for all applicants before admission, but this was not followed in these cases.

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