A resident admitted with major depressive disorder had a PASARR Level I screen indicating suspected serious mental illness, but the medical record did not include a PASARR Level II screen. The SW confirmed she was responsible for obtaining PASARR screenings and stated the resident should have had a Level II screen completed but did not.
PASARR screening was not completed appropriately for 3 residents reviewed. One resident with anxiety-related diagnoses had no Level II PASARR despite the facility’s Level I screen, another resident with major depressive disorder, anxiety, and depression had a positive Level I screen but no Level II documentation, and a third resident with schizophrenia and anxiety had no PASARR 1 or PASARR 2 completed even though the record showed a hospital discharge exemption.
A resident admitted with PTSD, anxiety, depression, personality disorder, and mood disorder did not have a required Level II PASARR completed after a Level I PASARR identified a major mental disorder and a 30-day exemption. The resident had intact cognition on BIMS and was observed ambulatory and independent with eating, toileting, and transfers. SS confirmed no follow-up PASARR II had been completed.
A resident with cerebral palsy, epilepsy, hydrocephalus, bipolar disorder, major depressive disorder, anxiety disorder, and severely impaired cognition had a PASARR Level 1 indicating a Level 2 was required, but the facility could not initially locate the Level 2 in the record. The NHA later provided a document identified as the Level 2, but it did not show when it was completed or submitted, and the facility could not determine the submission date.
PASRR screening was not accurately completed for a resident with schizoaffective disorder and anxiety disorder. The Level I screen did not reflect the resident’s mental health diagnoses or lorazepam order, and no Level II screen was submitted based on the incomplete information. Staff stated they did not initiate a Level II review because the resident was not on medication for schizoaffective disorder at admission, and later verified the omission and need for Level II review when lorazepam was ordered.
PASARR screening was not completed appropriately for one resident with schizophrenia and bipolar disorder. The resident’s PASARR Level I showed a major mental disorder, symptoms suggesting major mental illness, psychotropic medication use, and a history of ID, but it also listed a hospital discharge exemption with no Level II required. The MDS Nurse said she relied on SS for the Level I, and SS later confirmed the resident was past the 30-day exemption period after the planned group home placement fell through.
PASRR screening was not completed appropriately for a resident admitted with neurocognitive disorder with Lewy Bodies, Parkinson's disease, and dementia. Surveyors found no PASRR Level II on file, and both the Admissions Director and NHA stated that a Level II would have been expected based on the Level I screen.
PASRR screening was not completed for a resident reviewed for PASRR compliance. The resident had diagnoses including Parkinson’s disease, depression, and insomnia due to another mental disorder, and the NHA could not locate a PASRR on file. The DON stated that if PASRR was in the facility policy, it should have been completed.
Failure to complete PASARR Level II screening for a resident with schizoaffective disorder, dementia with behavioral disturbance, anxiety, and unspecified intellectual disabilities. The Level I PASARR was positive for a major mental disorder and psychotropic use, and the resident remained in the facility after the 30-day hospital discharge exemption expired. The DON/ADON and admissions staff confirmed no Level II was in the chart.
Failure to Complete Required PASRR Level II Screens: The facility did not complete required PASRR follow-up for 4 residents whose Level I 30-day hospital exemptions expired. Residents had diagnoses including depression, anxiety, dementia, intellectual disability, cerebral palsy, and other mental disorders, and records showed no Level II PASRR screening after the initial Level I screens. The SSD and VPS confirmed the missing PASRR Level II screens.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.