Inaccurate PASARR Screenings for Residents With Depression
Penalty
Summary
The deficiency involves the facility’s failure to ensure Level 1 PASARR screenings were reviewed for accuracy and completion for four residents with documented mental health diagnoses. Record review showed that one resident was initially admitted with a diagnosis of depression, and this diagnosis was also documented on the resident’s MDS dated 01/15/26. However, the resident’s PASARR Level 1 Identification Screen dated 07/29/24 indicated “No” to having a diagnosis or suspected mental illness, and the depression diagnosis was not reflected on the PASARR. For a second resident, the face sheet showed admission with certain diagnoses, and the PASARR Level 1 dated 01/10/26 documented no diagnosis or suspected mental illness, while the MDS indicated a diagnosis of depression and use of an antidepressant. For a third resident, the PASARR Level 1 dated 02/05/26 documented no diagnosis or suspected mental illness, while the face sheet listed diagnoses at admission and the MDS showed a diagnosis of depression and receipt of an antidepressant. For a fourth resident, the PASARR Level 1 dated 08/26/25 also indicated no diagnosis or suspected mental illness, despite the face sheet listing admission diagnoses and the MDS documenting depression and antidepressant use. In an interview on 03/12/26, the Administrator confirmed that all four residents had diagnoses of depression and acknowledged that these mental health diagnoses were not reflected on their PASARRs, and that updated PASARRs should have included the depression diagnoses.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.