Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a required Level II Pre-admission Screening and Resident Review (PASARR) was completed for a resident with multiple mental health diagnoses. The resident was admitted with diagnoses including Personality Disorder, Suicidal Ideation, Major Depressive Disorder, Generalized Anxiety Disorder, and Post-traumatic Stress Disorder. Documentation, including the Minimum Data Set (MDS) and a Senior LinkAge Line report, indicated the resident had intact cognition, was able to communicate needs, and had a primary diagnosis of severe major depressive disorder. The documentation also confirmed that the resident met criteria for mental illness and required a Level II PASARR evaluation prior to admission. Despite the Level I PASARR being completed and indicating the need for a Level II PASARR, facility staff, including the assistant director of nursing (ADON), director of nursing (DON), and regional consulting registered nurse (RC-RN), confirmed that the Level II PASARR was not completed. The facility's policy required completion of a Level I PASARR for all new admissions and a Level II PASARR as indicated before admission, but this process was not followed for the resident in question.