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F0645
D

Failure to Complete Accurate PASRR Screening for Mental Health Disorder

Laona, Wisconsin Survey Completed on 06-18-2025

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 Pre-admission Screening and Resident Review (PASRR) Level II Screen was completed for one resident who had a diagnosis of major depressive disorder and was prescribed mirtazapine, an antidepressant. The resident's PASRR Level I Screen, which was completed after admission, inaccurately indicated that the resident did not have a major mental health disorder and was not prescribed psychotropic medication for such a disorder. As a result, a PASRR Level II Screen was not submitted to determine the need for specialized services. Record review and staff interview confirmed that the resident was admitted with a diagnosis of major depressive disorder and was receiving antidepressant medication. The facility's policy requires accurate completion of the PASRR Level I Screen prior to admission, and a positive screen should trigger a Level II evaluation by the state-designated authority. However, the Level I Screen omitted the resident's mental health diagnosis and medication, leading to the failure to initiate the required Level II evaluation.

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