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F0645
D

Failure to Complete Accurate and Timely PASARR Screenings

Glendale, Wisconsin Survey Completed on 05-22-2025

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 and timely PASARR (Preadmission Screening and Resident Review) screenings for residents with potential mental disorders or intellectual disabilities. For one resident, a PASARR Level 1 screen was completed prior to admission and a 30-day hospital exemption was documented, which allowed admission without a Level 2 screen. However, after the resident remained in the facility beyond the 30-day exemption period, the facility did not resubmit a PASARR Level 1 as required. The Nursing Home Administrator confirmed that a follow-up PASARR was not completed prior to the expiration of the exemption, despite the resident having diagnoses of dementia and unspecified psychosis and being prescribed antipsychotic and antianxiety medications. For another resident, the facility failed to accurately document the presence of a serious mental illness on the PASARR Level 1 screen. The resident was admitted with diagnoses including anxiety disorder and unspecified psychosis, both of which are considered major mental disorders under DSM-5 criteria. Despite this, the PASARR Level 1 indicated that the resident did not have a major mental disorder, which prevented the initiation of a Level 2 PASARR evaluation. The Nursing Home Administrator stated that the answer was marked "NO" because there was no diagnosis to substantiate a "YES," even though the resident's medical record included relevant diagnoses. These deficiencies were identified through interview and record review by surveyors, who noted that the facility's practices did not align with its own policy and state requirements for PASARR screening. The lack of accurate and timely PASARR assessments resulted in residents not being properly evaluated for serious mental illness or intellectual disability as required.

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