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F0644
D

Failure to Complete PASRR Level II for Residents with New Mental Health Diagnoses

Mooresville, North Carolina Survey Completed on 05-15-2025

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 a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents who received new mental health diagnoses after admission. For both residents, a PASRR Level I was completed prior to admission, with recommendations to resubmit paperwork for a Level II review if a new mental health diagnosis was made or if there was a significant change in condition. Despite both residents being diagnosed with bipolar disorder and major depressive disorder after admission, no PASRR Level II was completed for either individual. Interviews with the responsible social worker revealed a lack of awareness regarding the requirement to complete PASRR Level II assessments for residents who receive new mental health diagnoses after admission or readmission. The social worker indicated that she typically only completed Level II paperwork for residents with limited Level II status or when required by periodic review or a change in condition. The administrator confirmed that PASRR Level II should be completed in a timely manner upon admission, readmission, or when a new mental health diagnosis is made, acknowledging that the required assessments were not performed for the two residents in question.

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