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F0644
D

Failure to Complete PASRR Screening for Resident with New Mental Health Diagnoses

Fayetteville, North Carolina Survey Completed on 09-12-2025

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 complete a Preadmission Screening and Resident Review (PASRR) application for a resident who was readmitted with newly identified mental health diagnoses, including unspecified psychosis not due to a substance or known physiological condition and psychotic disorder with hallucinations due to a known physiological condition. Upon review of records and staff interviews, it was found that the resident's admission Minimum Data Set (MDS) indicated severe cognitive impairment and listed relevant psychiatric diagnoses, but the state Level II PASRR process had not been initiated to assess for serious mental illness or intellectual disability. The Social Worker, who was responsible for PASRR screenings, confirmed that a Level II PASRR should have been completed at the time of readmission with the new diagnoses. The Director of Nursing also stated that the Social Worker was expected to complete PASRR Level II screenings for all residents with mental health diagnoses.

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