Failure to Conduct Timely PASRR Assessments for Residents with Serious Mental Disorders
Summary
The facility failed to refer five residents for Preadmission Screening and Resident Review (PASRR) Level I and II assessments, which are necessary for residents with serious mental disorders. The Director of Social Services, identified as V4, acknowledged that these assessments were not completed for residents R2, R3, R4, R5, and R6. Each of these residents had diagnoses indicating serious mental illness, such as schizoaffective disorder, major depressive disorder, and bipolar disorder, which required timely PASRR evaluations to ensure they received appropriate care and services. The deficiency was partly due to a transition period in the facility's social services department, during which there was no Social Services Director to manage the PASRR process. V4, who was new to the facility, was unaware of the need for these assessments until the surveyor's interview. The facility's business office manager, V5, confirmed that the absence of a Social Services Director led to a lack of communication with the appointed screening agency, resulting in missed PASRR evaluations. The facility's policy requires that newly admitted residents with serious mental illness, intellectual disability, or developmental disability be assessed for PASRR Level II within a specified timeframe. However, due to the oversight, the necessary assessments were not conducted, leaving the residents without the specialized programs and treatment goals they needed. Notifications from the assessment tool and service letters from the screening agency were not acted upon, contributing to the deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with type 2 DM, depression, mood disorders, osteomyelitis, and moderately impaired cognition had a new diagnosis of bipolar disorder type two added to the medical record, but the facility did not obtain an updated PASARR to reflect this qualifying mental health condition. The existing PASARR did not include the bipolar diagnosis, and this lack of PASARR update was confirmed by the corporate DON during surveyor interview.
A resident with multiple psychiatric diagnoses and mildly impaired cognition had Level II PASARR recommendations that were not implemented by facility staff. The PASARR outcome required 1:1 staffing due to a history of head banging and fire starting, removal of self-injurious items from reach, group therapy with a trained group therapist, a behavior management safety plan, and ongoing evaluation of psychotropic medications. Record review and interview with the staff member serving as Social Service Director confirmed that none of these interventions had been addressed or put into place, even though the resident had not displayed head banging, self-injurious behavior, or fire starting since admission.
A resident with multiple psychiatric and medical diagnoses, including bipolar disorder, PTSD, and a history of suicidal behavior, was hospitalized for suicidal ideations with a plan and returned with new diagnoses of GAD and suicidal ideations. Review of the chart found no evidence that the Ohio Department of Mental Health was notified for PASRR review, and a Social Service Designee confirmed the notification was not made.
A resident’s PASARR was not updated after new mental illness diagnoses were added. The resident had dementia, major depressive disorder, generalized anxiety, and delusional disorders, and the existing PASARR incorrectly indicated no mental disorder diagnosis. The DON confirmed the PASARR should have been updated.
A resident with fracture, spinal stenosis, dementia, and bipolar disorder had antipsychotic orders for quetiapine, but the PASRR incorrectly stated there were no antipsychotic meds in the prior 6 months. Social Services confirmed the PASRR omitted the resident’s psychotropic meds and was not completed accurately.
PASARR screenings were not updated after new mental health and cognitive diagnoses were added for three residents. Records showed one resident with dementia, bipolar disorder, depression, and anxiety had no updated PASARR after new diagnoses were entered; another resident with severe cognitive impairment and multiple psychiatric/cognitive diagnoses had an outdated PASARR that still omitted several conditions; and a third resident with impaired cognition and paranoid schizophrenia had no new PASARR after the diagnosis was added. The DSS confirmed the missed updates.
Failure to Update PASARR After New Bipolar Disorder Diagnosis
Penalty
Summary
Surveyors identified a deficiency in the facility’s coordination of PASARR with resident assessments and care planning when a required PASARR update was not completed after a new qualifying mental health diagnosis was added. Resident #66 was admitted on 05/14/23 with diagnoses including type 2 diabetes mellitus, depression, mood disorders, and osteomyelitis. The most recent PASARR for this resident, dated 06/08/23, did not include a diagnosis of bipolar disorder type two. The resident’s diagnosis list showed that bipolar disorder type two was added as a new mental health diagnosis on 08/20/25, and an MDS assessment dated 01/12/26 documented moderately impaired cognition. Despite this new serious mental health diagnosis, the facility did not complete a new PASARR for the resident, which was confirmed in an interview on 03/25/26 at 11:43 a.m. with the Corporate Director of Nursing, who verified that no updated PASARR had been obtained following the addition of the bipolar disorder diagnosis.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #66 on 03/26/2026. It was determined that there were no negative effects related to the missing Pre-Admission Screening & Resident Review (PASARR) identified during Annual Survey. On or before 04/30/2026, LNHA/Designee will a PASAR referral for Resident #66. The facility will ensure receipt and incorporation of PASARR findings into the resident's medical record, care plan, and service upon completion, as appropriate. LNHA notified Resident #66's primary care provider on 03/26/2026 of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged the missing Pre-Admission Screening & Resident Review (PASARR) and that there were no negative effects related to the lack of behavioral monitoring. No new orders received from primary care provider. On or before 04/30/2026, LNHA/Designee will review other residents' medical records to ensure that current residents have a Pre-Admission Screening & Resident Review (PASARR) on file. Also, on or before 04/30/2026, LNHA/Designee will evaluate list of residents and their diagnosis list(s). LNHA/Designee will evaluate diagnoses and Pre-Admission Screening & Resident Reviews (PASARR) to ensure that any diagnosis of a mental disorder and/or intellectual disability have been captured on a Pre-Admission Screening & Resident Reviews (PASARR). Any missing Pre-Admission Screening & Reviews (PASARRs) will be completed. On or before 04/30/2026, LNHA/Designee will educate Social Service Designee (SSD) in the following: 483.20(e)(2) Coordination of PASARR and Assessments §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Also, on or before 04/30/2026, LNHA/Designee will also educate Social Service Designee (SSD) that a Pre-Admission Screening & Resident Review (PASARR) is required with all new admissions and with any new mental health or intellectual disability diagnoses. LNHA/Designee will complete audits x5 residents/medical records weekly x4 weeks; then as determined by QAA. The audits will ensure that PASARR referrals are made when a resident: • Newly admits to the facility • Have a new diagnosis of serious mental illness, intellectual disability (ID), or related condition, and/or • Have had a significant change in status indicating a potential PASARR Level II trigger, and/or The audit will include: • Review of admission records • Diagnosis lists • Psychiatric consults MDS Section P Existing PASARR documentation Any resident lacking a required PASARR or with incomplete PASARR documentation will be referred immediately for PASARR review. Company policy/procedure was reviewed and no additional changes are required at this time. Education and ongoing monitoring is sufficient in ensuring regulatory compliance.
Failure to Implement Level II PASARR Recommendations
Penalty
Summary
The facility failed to ensure that Level II PASARR recommendations were implemented timely and appropriately for one resident. The resident was admitted with multiple psychiatric diagnoses, including bipolar disorder, schizoaffective disorder, personality disorder, anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder, and was assessed as having mildly impaired cognition on a quarterly MDS assessment. A Notice of PASRR Level II Outcome dated 08/25/25 specified several recommendations: 1:1 staffing due to a history of head banging and fire starting, keeping self-injurious items out of reach, provision of group therapy with a trained group therapist, development of a behavior management safety plan to decrease inappropriate behaviors and ensure safety, and ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. Record review and staff interview showed that these PASARR recommendations were not addressed or implemented as required. The Business Office Manager, who was serving as Social Service Director at the time the Level II PASARR recommendations were issued, confirmed that the recommended 1:1 staffing, environmental controls to remove self-injurious items, group therapy, behavior management safety plan, and ongoing psychotropic medication evaluation had not been put into place. The same staff member also confirmed that the resident had not exhibited head banging, self-injurious behavior, or fire starting since admission, but the PASARR-directed interventions still had not been implemented.
Failure to Notify State Agency of Mental Health Change
Penalty
Summary
The facility failed to notify the appropriate state agency, the Ohio Department of Mental Health, of a significant change in a resident’s mental health condition as required for PASRR review. Resident #1 was admitted with diagnoses including bipolar disorder, PTSD, mild cognitive impairment, Parkinsonism, chronic kidney disease, diabetes, insomnia, osteoarthritis, and a personal history of suicidal behavior. The resident later had an inpatient psychiatric hospitalization for suicidal ideations with a plan, and upon return to the facility had additional diagnoses of generalized anxiety disorder and suicidal ideations documented in the discharge summary. Review of the electronic and hard charts found no evidence that the state agency was notified of the new diagnoses or decline, and a Social Service Designee confirmed the notification had not been made.
PASARR Not Updated After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure an updated Preadmission Screening and Resident Review (PASARR) was completed when a resident was diagnosed with a new mental illness diagnosis. Resident #53 was admitted on 05/29/2020 and had diagnoses including dementia, major depressive disorder, generalized anxiety, and delusional disorders. The resident’s quarterly MDS 3.0 assessment showed a BIMS score of 12 out of 15, indicating moderately impaired cognition for daily decision-making abilities. Review of the electronically uploaded PASARR dated 03/11/2020 showed that the question asking whether the resident had a diagnosis of any mental disorders was marked “no.” During interview on 09/30/2025 at 2:13 P.M., the DON confirmed the PASARR was not updated and should have been with the newly added mental illness diagnosis.
Inaccurate PASRR Medication Documentation
Penalty
Summary
The facility failed to ensure the Preadmission and Resident Review (PASRR) was completed accurately for one resident. The resident was admitted with diagnoses including displaced fracture, spinal stenosis, unspecified dementia, and bipolar disorder. The medical record showed orders for Quetiapine Fumarate 25 mg every six hours as needed for agitation and Quetiapine Fumarate ER 200 mg at bedtime for bipolar disorder, both beginning on admission. However, the PASRR completed later stated the resident had not been prescribed any antipsychotic medications within the prior six months, which was inaccurate because the antipsychotic orders were omitted from the assessment. Social Services confirmed the PASRR did not document the resident's psychotropic medications accurately and acknowledged the orders had been incorrectly eliminated from the assessment.
PASARR screenings not updated after new mental health diagnoses
Penalty
Summary
The facility failed to ensure resident PASARR screenings were updated after new diagnoses were added to residents’ medical records. Review of records, staff interviews, and facility policy showed that three residents had mental health or cognitive diagnoses added after their most recent PASARR reviews, but the screenings were not updated at the time those diagnoses were identified. The Social Services Director confirmed that updated PASARRs had not been completed for these residents before surveyor review. For one resident, the medical record showed diagnoses including dementia, bipolar disorder, depression, anxiety, peripheral vascular disease, diabetes, and chronic kidney disease. The resident’s PASARR dated 09/03/23 listed dementia, but later additions of bipolar disorder, anxiety, and depression were not reflected in an updated PASARR. The Social Services Director verified on 01/15/26 that no updated PASARR had been completed. For another resident, the record showed severe cognitive impairment with a BIMS score of one and multiple diagnoses including neurocognitive disorder with Lewy bodies, dementia with behavioral disturbance, bipolar disorder, major depressive disorder, anxiety disorder due to a known physiological condition, insomnia, and cognitive communication deficit. The most recent PASARR before surveyor intervention was dated 09/02/23 and did not reflect the newer diagnoses, and the PASARR completed on 01/15/26 still omitted several of those conditions. For a third resident, the record showed impaired cognition and diagnoses including paranoid schizophrenia, but the PAS/RR dated 07/17/21 did not identify that diagnosis. The DSS confirmed that paranoid schizophrenia had been added to the medical record in December 2024 and that another PASARR screening should have been completed at that time.
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