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F0644
D

Failure to Update PASRR Screens After Changes in Mental Health Diagnoses and Medications

Sheboygan, Wisconsin Survey Completed on 04-30-2025

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 Pre-admission Screening and Resident Review (PASRR) Level I Screens were updated and, when indicated, Level II Screens were initiated for residents who experienced changes in mental health diagnoses and psychotropic medication orders. For one resident, who had diagnoses including dementia, anxiety, depression, and psychotic disorder, the medical record showed a severely impaired cognitive status and new or changed orders for antianxiety, antipsychotic, and antidepressant medications. Despite these changes, the resident's PASRR Level I Screen was not updated, nor was a Level II Screen completed, as required when new mental disorders or psychotropic medications are identified. Similarly, another resident with multiple neurocognitive and psychiatric diagnoses, including major depressive disorder and anxiety disorder, received new or changed orders for several psychotropic medications, such as antianxiety, anticonvulsant, antidepressant, and antipsychotic drugs. The resident's PASRR Level I and Level II Screens were not updated to reflect these changes. Staff interviews confirmed that the responsible personnel were aware of the medication and diagnosis changes but did not update or resubmit the required PASRR screenings.

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