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 Pre-admission Screening and Resident Review (PASRR) level 2 comprehensive evaluations were obtained for two residents who were identified as requiring further assessment for serious mental illness (SMI) after their level 1 PASRR screenings. For one resident with a diagnosis of depression who began antidepressant treatment, the facility delayed updating the level 1 PASRR for four months and did not follow up to obtain the required level 2 evaluation. The resident's records showed no evidence of a level 2 PASRR being completed, despite the ongoing use of antidepressant medication and the initial identification of SMI. For another resident with a psychiatric mood disorder, the facility's records indicated that a level 2 PASRR evaluation was required, but there was no documentation of the evaluation being completed. Although a referral for the level 2 evaluation was reportedly sent, there was a delay of over a year and three months before any follow-up occurred. Staff interviews confirmed awareness of these delays and lapses in the PASRR process, with staff citing workload and external factors as reasons for the lack of timely follow-up.