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F0644
D

Failure to Submit Level II PASRR Evaluation for Resident with New Serious Mental Illness Diagnosis

Charlotte, North Carolina Survey Completed on 12-18-2025

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 submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who received a new diagnosis of a serious mental illness after admission. The resident was initially admitted with diagnoses of lymphedema, cellulitis, and an open wound, and a Level I PASRR was completed prior to admission. Subsequent medical record review showed that the resident was later diagnosed with major depressive disorder and paranoid personality disorder, and was receiving antidepressant and anticonvulsant medications. Despite these new diagnoses, there was no evidence in the electronic medical record that a Level II PASRR evaluation request was submitted. Interviews with facility staff revealed that the process for submitting a Level II PASRR evaluation involved nursing notifying the social worker (SW) when a resident received a new diagnosis of a serious mental illness. The SW was then responsible for submitting the request. Both the SW and the Director of Nursing (DON) acknowledged that the request for a Level II PASRR evaluation was not submitted for this resident due to an oversight. The administrator confirmed that a request should have been made when a new qualifying mental health diagnosis was identified.

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