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F0644
E

Failure to Update PASRR Referrals for Residents with New Mental Health Diagnoses

Freeport, Illinois Survey Completed on 11-19-2025

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 residents with new diagnoses of mental health disorders were referred to the state-designated authority for Pre-admission Screening and Resident Review (PASRR) as required. Specifically, four residents were identified who had new or updated mental health diagnoses, such as schizophrenia, major depressive disorder, schizoaffective disorder, and insomnia, after their initial admission and original PASRR screenings. Despite these new diagnoses, there was no evidence that updated PASRR screenings or referrals were completed for these residents. Interviews with the facility liaison confirmed that these omissions were discovered during an audit, and the liaison was previously unaware that new diagnoses required updated PASRR referrals. Record reviews showed that the original PASRR or OBRA screens for these residents did not reflect their subsequent mental health diagnoses. For example, one resident was prescribed antipsychotic medication following reports of aggressive behavior and mood swings, and another had a diagnosis of schizophrenia added years after admission, yet neither had an updated PASRR. The facility's PASRR policy also lacked guidance on updating screenings when new qualifying diagnoses are identified.

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