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F0641
E

Inaccurate PASRR Status Coding on MDS Assessments

Westlake, Ohio Survey Completed on 06-11-2025

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 accurate coding of the Preadmission Screening and Resident Review (PASRR) status on the Minimum Data Set (MDS) assessments for four residents with a documented level two mental illness. Record reviews showed that each of these residents had a PASRR level two assessment indicating serious mental illness, yet their most recent comprehensive MDS assessments incorrectly recorded their PASRR status as 'No' to the question regarding current consideration by the state level II PASRR process for serious mental illness or intellectual disability. The affected residents had diagnoses including schizophrenia, opioid dependence, delusional disorder, schizoaffective disorder, suicidal ideations, adjustment disorder, paranoid schizophrenia, muscle weakness, chronic obstructive pulmonary disease, and hypertension. Staff interview with the MDS nurse confirmed that these residents were determined by the state to have a level two mental illness and acknowledged the inaccurate coding of their PASRR status on the MDS assessments.

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