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F0645
D

Failure to Accurately Review PASARR Screenings for Mental Disorders

Bloomfield, New Mexico Survey Completed on 11-18-2025

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 Level 1 Preadmission Screening and Resident Review (PASARR) screenings were reviewed for accuracy and completion for three residents. Specifically, for one resident with diagnoses of dementia and depression, the PASARR Level 1 Identification Screen completed by a previous facility did not include the resident's diagnosis of depression, despite depression being listed as a mental illness example on the screening form. The resident's Minimum Data Set (MDS) confirmed a diagnosis of depression and the use of antidepressant medication, indicating a discrepancy between the PASARR and the resident's actual medical condition. Interviews with facility staff revealed that both the Marketing Director and the Director of Social Services were responsible for verifying the accuracy of PASARR screenings prior to admission. However, both staff members were new to their positions and did not review the resident's Level 1 PASARR for accuracy. The Marketing Director acknowledged that the PASARR was incorrect due to the missing depression diagnosis and stated that it was expected for all PASARRs to be screened before admission. The Social Services Director also confirmed the expectation for accurate PASARRs and noted that improper screening could result in residents not receiving necessary care or services.

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