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 required Pre-Admission Screening and Resident Review (PASRR) processes were completed for three out of five residents reviewed. For one resident with diagnoses of anxiety and depression, the PASRR Level 1 screen indicated the need for a Level 2 evaluation prior to admission, but there was no evidence in the electronic health record that this evaluation was completed. Staff interviews revealed a lack of awareness regarding the requirement for a Level 2 evaluation before admission when indicated by a positive Level 1 screen. For two other residents, the PASRR Level 1 screens documented indicators of serious mental illness and granted a 30-day exemption from Level 2 evaluation, contingent on discharge within that period. However, when these residents remained beyond 30 days, there was no evidence that updated PASRR Level 1 screens or required Level 2 evaluations were completed. Staff confirmed that no requests for Level 2 evaluations were submitted for these residents, despite the extended stays.