F0645

D

Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness

King, North Carolina Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with serious mental illness. Documentation showed the resident had a Level I PASRR determination dated 10/24/22 with no expiration date and was admitted in April 2025 with diagnoses including major depression, post-traumatic stress disorder (PTSD), and anxiety. The admission MDS assessment documented that the resident had a serious mental illness and/or intellectual disability and was receiving antidepressant medications, with pertinent diagnoses of major depression, insomnia, anxiety, and PTSD. A psychiatric progress note dated 9/29/25 further confirmed ongoing treatment for major depressive disorder, PTSD, and insomnia with duloxetine and trazodone.

Record review revealed no evidence that a Level II PASRR evaluation had ever been requested or completed for this resident. The facility was unable to provide documentation that a request for a Level II PASRR evaluation had been submitted. In an interview, the Social Worker stated the resident was admitted with a Level I PASRR and acknowledged she had not submitted a Level II request, explaining that she typically identified new admissions needing PASRR screening through morning meetings and must have inadvertently missed this resident. In a separate interview, the Administrator reported uncertainty about whether Level II PASRR requests had been submitted for this or any resident and stated an expectation that the Social Worker would request a new Level II PASRR evaluation for residents admitted with serious mental health diagnoses, even if they had a prior Level I from another facility.