F0644

E

Failure to Resubmit PASARR for Newly Identified Serious Mental Disorders

Chicago, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The facility failed to coordinate assessments with the PASARR program by not referring a resident for a Level II PASARR evaluation after the development or identification of serious mental health conditions. At admission on 10/10/2024, the Admissions Director completed a Level I PASARR for the resident and indicated there were no known or suspected mental health diagnoses and no mental health medications, resulting in a determination that no Level II PASARR was required. The original Profile Face Sheet reflected this initial assessment. However, the resident’s current Profile Face Sheet later documented multiple mental health diagnoses, including major depressive disorder, recurrent severe without psychotic features; generalized anxiety disorder; post-traumatic stress disorder; and adjustment disorder with mixed anxiety and depressed mood.

The resident’s physician orders also showed prescriptions for Remeron and Escitalopram, both antidepressant medications, indicating active treatment for mental health conditions. When surveyors requested updated PASARR documentation, the Executive Director confirmed that the facility had not resubmitted the resident for a Level II PASARR evaluation despite these new or newly identified mental health diagnoses. The Executive Director further stated that the Admissions Director and Social Services staff submit PASARR information to the state-designated authority but had not done so for this resident and were not aware that resubmission for Level II PASARRs was required when new serious mental disorders are identified. The facility’s PASRR policy, last revised in April 2025, did not include a process for resubmitting residents for a Level II PASARR when newly evident or possible serious mental disorders, intellectual disabilities, or related conditions are identified.