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F0645
D

Failure to Accurately Complete PASARR Screening for Mental Illness

Belen, 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 the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected a resident's diagnosis of major depressive disorder. According to the facility's policy, the Social Worker or designated staff are responsible for ensuring that all patients with mental disorders receive appropriate pre-admission screenings in accordance with federal and state regulations. Record review showed that a resident was admitted with diagnoses including liver disease, dementia, and major depressive disorder. The resident's Minimum Data Set (MDS) assessment documented symptoms consistent with depression, such as little interest or pleasure in activities, feeling down, poor appetite, low energy, trouble concentrating, and impaired memory and decision-making. The MDS also indicated a moderate cognitive impairment and specifically noted depression as a psychiatric/mood disorder. Despite this documented diagnosis and symptoms, the PASARR Level I Identification Screening completed for the resident indicated that the resident did not have a diagnosis of or a suspected mental illness. During an interview, the Social Services Director confirmed that the PASARR screening was incorrect and acknowledged that staff should have documented the resident's diagnosis of major depressive disorder.

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