Failure to Complete Level II PASRR After Significant Change in Mental Status
Summary
The facility failed to ensure that one resident had a Level II PASRR completed after significant changes in treatment needs. The resident’s initial PASRR dated 12/20/23 indicated she did not have an intellectual or developmental disability and did not have a serious mental illness, and that a Level II PASRR was not required unless she developed a serious mental illness, IDD, or a significant change in treatment needs. She was admitted to the facility and later developed multiple mental health diagnoses during her stay, including anxiety disorder on 8/15/24 and major depressive disorder on 4/21/25. During the resident’s stay, physician orders were received for psychotropic medications to treat her mental health conditions and behaviors, including buspirone, quetiapine, bupropion, mirtazapine, and an additional dose of quetiapine after she was later diagnosed with dementia with behavioral disturbances on 8/19/25. Her 8/13/25 BIMS score was 0, indicating severe cognitive impairment, and staff documented that she had severely impaired daily decision-making skills, rarely or never understood others, and had memory problems, inattention, and disorganized thinking. No documentation in her EMR showed that a Level II PASRR had been completed after the significant change in treatment needs. The DON stated she did not complete PASRR screenings and that the SSD was responsible for them. The SSD confirmed she was responsible for PASRR screenings, stated she was unaware that a Level II PASRR should be completed when a resident experienced a significant change in mental or physical condition, and confirmed she had not completed a Level II PASRR for the resident. She also confirmed the resident should have had a Level II PASRR completed when she started on an antipsychotic medication. The facility policy stated that PASRR resident review is required upon a significant change in mental or physical condition and that PASRR documents should be available in the active chart.
Penalty
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Below are regulatory guidelines relevant to this citation:
Failure to Coordinate PASRR Assessment for a Resident Staying Beyond Approved Convalescent Period: A resident with vascular dementia, PTSD, and depression remained in the facility beyond the PASRR-approved convalescent care period, but the facility did not notify SDS as required or obtain a PASRR Level II evaluation. The DON could not locate documentation of a Level II review, and SDS confirmed it had not been notified of the ongoing LTC stay and that the case was non-compliant with the PASRR process.
A resident with a documented hx of TBI had a PASRR that did not check the related condition, even though the admission MDS and physician notes identified TBI and other significant diagnoses including vascular dementia, AFib, anemia, HTN, HLD, pulmonary fibrosis, speech and language deficits, cerebrovascular disease, and Parkinson’s disease. The DON confirmed the TBI hx should have been reflected on the PASRR and that the PASRR needed to be updated.
A resident with spina bifida, hydrocephalus, and cerebral palsy had PASRR II recommendations for a customized manual wheelchair plus OT and PT, but the facility’s NFSS submissions were denied because required signatures were missing, requests were not responded to, and assessments expired before authorization. Staff interviews showed the ADM had no PASRR policy and the MDS nurse was unsure how PASRR specialized services and timelines worked.
A resident with a history of MS, dementia, and depression had a PASRR completed before admission that did not identify a serious mental illness. Later, the resident’s MDS indicated Bipolar disorder, but the record lacked evidence that the facility referred the resident for the required PASRR Level II review, and the RN Assessment Coordinator Office Manager confirmed the referral was not made.
A resident with bipolar disorder was not referred to the SMHA for a PASRR level II review after the diagnosis was added to the record but not identified on the PAS level I. The SSD said she had not been reviewing the PAS for level II needs and had not notified the county, even though the resident was being seen by psychiatry.
A facility failed to complete a PASRR Resident Review/status change for a resident after schizophrenia was documented in the chart. The resident’s admission record, H&P, and MDS all reflected schizophrenia, but the record lacked evidence that a PASRR resident review or status change was submitted after the diagnosis was updated; the MDS Coordinator acknowledged the omission, and the Administrator was informed.
Failure to Coordinate PASRR Assessment for Resident Staying Beyond Approved Convalescent Period
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for a resident admitted with diagnoses including vascular dementia, PTSD, and unspecified depression. The resident's PASRR Level I determination specified convalescent care for 90 days or less and stated that if the individual stayed beyond 90 days, an individualized PASRR Level II evaluation had to be completed, with the facility required to notify SDS on day 85 that the resident would need services beyond 90 days. Record review and interview showed the resident remained in the facility beyond the approved convalescent care period, but the facility did not notify SDS by the required date and no PASRR Level II evaluation was found. The DON stated the facility could not locate any record showing the resident received a PASRR Level II evaluation or that SDS had been contacted to continue the assessment process. Email correspondence from SDS confirmed it had not been notified of the ongoing LTC stay and that the case was non-compliant with the PASRR process.
PASRR Did Not Reflect Resident’s Traumatic Brain Injury
Penalty
Summary
The facility failed to ensure that a resident with a known history of traumatic brain injury had a coordinated PASRR review that reflected the diagnosis. Review of the resident’s PASRR showed no related conditions, including traumatic brain injury, checked off, while the admission MDS documented personal history of traumatic brain injury under active diagnoses. Physician progress notes also identified a past medical history that included traumatic brain injury along with vascular dementia, atrial fibrillation, anemia, hypertension, hyperlipidemia, pulmonary fibrosis, speech and language deficits, cerebrovascular disease, and Parkinson’s disease. During interview, the DON confirmed the resident had a history of traumatic brain injury and stated the PASRR needed to be updated. The facility policy stated residents with a newly evident or possible serious mental disorder, intellectual disability, or related condition are to be referred promptly for a level II resident review, including when a related condition was not previously identified and evaluated through PASARR.
PASRR Recommendations Not Incorporated Into Care Planning and NFSS Submissions
Penalty
Summary
The facility failed to incorporate PASRR Level II recommendations into Resident #57’s assessment, care planning, and transitions of care. Resident #57 was admitted with diagnoses including spina bifida with hydrocephalus and cerebral palsy, had Medicaid coverage, and was cognitively intact with a BIMS score of 15/15. Her discharge MDS documented use of a wheelchair, and her care plan identified her as PASRR positive related to spina bifida with an intervention for a customized manual wheelchair. Record review showed the PASRR II meeting recommended a customized manual wheelchair and specialized services for OT and PT. The NFSS for the customized wheelchair was submitted but was denied multiple times because the required signature page was missing, the facility did not respond to a request, and later the assessment was over 30 days old and no longer valid. The NFSS requests for OT and PT were also denied because the assessments were over 30 days old and had passed the authorization period. Interviews with the ADM, MDS nurse, and DON confirmed the facility had no PASRR policy, the MDS nurse was new and unsure how PASRR specialized services and submission timelines worked, and the MDS nurse was responsible for PASRR residents and submitting NFSS.
Failure to Refer Resident for PASRR Level II Review After New Bipolar Diagnosis
Penalty
Summary
The facility failed to refer a resident for a PASRR Level II resident review after a new diagnosis of Bipolar disorder was identified on the resident’s MDS. The resident’s clinical record showed an admission diagnosis history that included Multiple Sclerosis, Dementia, and Depression, and the original PASRR completed before admission indicated that depression was managed with medication and did not identify a serious mental illness at that time. The resident’s MDS with an ARD of 11/26/24 marked Bipolar Disorder as present, but the clinical record lacked evidence that the facility referred the resident to the state mental health authority for a PASRR Level II review after that new diagnosis was documented. During interview, the RN Assessment Coordinator Office Manager confirmed that the facility did not make the required referral following the Bipolar diagnosis.
Failure to Refer Resident With Bipolar Disorder for PASRR Level II Review
Penalty
Summary
The facility failed to notify the designated State Mental Health Authority for 1 sampled resident who had a diagnosis of bipolar disorder that was not identified on the Pre-admission Screen. The resident’s quarterly MDS assessment dated 5/23/26 showed cognition was intact and no behaviors were displayed during the assessment period. The resident’s PAS level I completed on 10/09/2020 indicated there was no diagnosis of bipolar disorder or other mental illness, and a level II assessment was not required at that time. A diagnosis report dated 7/29/26 showed bipolar disorder had been added to the resident’s record on 4/29/21, but the medical record did not contain evidence that the resident was referred to the SMHA after that diagnosis was identified. During interview, the social service designee stated she had not been reviewing the PAS to ensure a level II screening was completed when needed and confirmed she had not notified the county for a level II referral, although the resident was being seen by psychiatry. The regional clinical service director stated the facility should review the PAS for accuracy and follow up with the mental health authority if a mental illness diagnosis was identified and not reflected on the PAS for level II screening.
Failure to Complete PASRR Resident Review After Schizophrenia Diagnosis
Penalty
Summary
The facility failed to comply with DHCS requirements for the PASRR process for one sampled resident with a diagnosis of schizophrenia. Resident 10 was admitted with undifferentiated schizophrenia listed in the admission record, and the H&P noted the resident had the capacity to understand and make decisions. The resident’s MDS assessment also showed a diagnosis of schizophrenia. Medical record review did not show documentation that the facility completed a Resident Review or status change screening to PASRR after the schizophrenia diagnosis was identified. During interview and concurrent record review, the MDS Coordinator stated the resident did not have the schizophrenia diagnosis from admission until the physician updated the diagnosis information in June 2026, and acknowledged that a resident review or status change should have been submitted to PASRR for the change in diagnosis related to serious mental illness. The Administrator was informed and acknowledged the findings.
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