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F0645
E

Failure to Complete PASARR Level II Screenings for Residents with Major Mental Disorders

Madison, Wisconsin Survey Completed on 07-29-2025

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 the required PASARR Level II (Preadmission Screening and Resident Review) screenings for four residents who were admitted with diagnoses of major mental disorders and prescribed psychotropic medications. Each of these residents was initially admitted under a hospital discharge exemption, which allows for a 30-day maximum stay without a Level II screening. However, all four residents remained in the facility beyond the 30-day exemption period, and there was no evidence that the necessary Level II screenings were completed as required by federal regulations and facility policy. For each resident, documentation showed that the Level I PASRR screens identified the presence of a major mental disorder and the use of psychotropic medications. Despite this, and the fact that their stays exceeded the 30-day exemption, the facility did not initiate or complete the Level II screening process. Interviews with social workers and the Assistant Nursing Home Administrator confirmed that the oversight occurred due to a change in staff responsibilities and a lack of follow-up to ensure the PASRR program was maintained during staff transitions. The deficiency was further substantiated by the facility's own policy, which mandates that all new admissions and readmissions be screened for mental disorders or intellectual disabilities per the PASRR process. The failure to complete the Level II screenings was acknowledged by staff during interviews, who indicated that the screenings should have been completed once it was clear the residents would remain in the facility beyond the permitted exemption period.

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