Failure to Implement PASARR-Recommended Customized Wheelchair Service
Summary
The deficiency involves the facility’s failure to incorporate PASARR Level II recommendations into a resident’s assessment, care planning, and transitions of care, specifically the provision of a customized manual wheelchair (CMWC) as a specialized service. The resident was an adult male with cerebral palsy, dementia, and speech disturbances, with a BIMS score of 03 indicating severe cognitive impairment and dependence on staff for ADLs. His care plan included requirements to complete and submit a new PL1 for any readmission or change of condition, notify the local authority and therapy department of PASARR-positive status, and hold an IDT meeting within 14 days of admission. A PASRR care plan meeting and PASRR Comprehensive Service Plan Form dated 08/06/25 documented that the IDT, including PASRR representatives, agreed the resident would receive habilitation coordination, independent living skills training, and a customized manual wheelchair as a new specialized service. Despite this agreement, the facility did not successfully submit the necessary NFSS request for the CMWC through the Simple LTC portal within the PASARR time frame. Portal records dated 08/15/25 and 11/07/25 showed the forms for the customized wheelchair were marked "form not accepted," and no NFSS was submitted. During observation, the resident was seen in a non-customized wheelchair, leaning to the left with his left hand dangling out of the chair, and attempts to interview him using a language line interpreter were unsuccessful due to unclear speech. The PTA reported that she recommended the CMWC at the PASRR meeting, the PASRR coordinator agreed, the wheelchair company assessed and measured the resident, and the physician signed the paperwork, but she was informed the NFSS was not accepted due to a discrepancy with the resident’s date of birth. Interviews with the MDS coordinator, DON, and business office manager revealed that the NFSS submission was rejected because of conflicting Social Security and date-of-birth information, and that the issue had been referred to the business office and corporate without resolution. The business office manager stated that the Social Security office had an older, incorrect date of birth that had become official and that she contacted an HHSC eligibility services clerk, who confirmed the birth date change in early August 2025. The PASRR staff reported that the facility did not reach out to PASARR support for assistance and explained that the facility should have inactivated the rejected PO1 and submitted a new one with the correct date of birth. The MDS coordinator stated that the head office changed the date on the declined PO1 but refused to cancel and resubmit it due to billing concerns, and she declined to contact PASARR support directly. The facility was unable to provide a PASRR policy when requested at entrance and exit interviews.
Penalty
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A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
A resident with diagnoses including disorganized schizophrenia, dementia with behavioral disturbance, developmental disorder of scholastic skills, and metabolic encephalopathy had a PASARR level two referral that was not acted upon. The resident’s care plan did not identify level two recommendations, and the DON confirmed the level two screening was not in the EMR. An OBRA Level 1 screening had identified serious mental illness and referred the resident for level two screening.
A resident with schizoaffective disorder, bipolar disorder, anxiety, severe cognitive impairment, and behavior issues had a PASRR Level 1 that did not reflect her mental health diagnoses. The DON, Regional MDS Nurse, and ADM stated that a new PASRR review should be completed when a new MI diagnosis is identified, but the facility did not complete a new PL1 when the resident’s diagnoses were documented.
The facility failed to ensure accurate PASRR Level I screenings and appropriate PASRR referrals for two residents with documented mental illness diagnoses. One resident’s records showed schizoaffective disorder, depression, generalized anxiety disorder, and schizophrenia, yet the PASRR Level I from the referring hospital indicated no mental illness. Another resident had depression, vascular dementia with psychotic disturbance and anxiety, and later a new diagnosis of schizophrenia, but her PASRR Level I also showed no mental illness and she was not referred for a PASRR Level II after the new schizophrenia diagnosis. The MDS Coordinator acknowledged that the PASRR for one resident should have been positive and corrected, and that she was unaware of the other resident’s new schizophrenia diagnosis and had not notified the local authority, while the DON and Administrator confirmed the MDS Coordinator’s responsibility for PASRR accuracy and follow‑through.
A resident with multiple diagnoses, including a right femur fracture and schizophrenia, was not properly identified for PASRR Level II evaluation because the schizophrenia diagnosis was omitted from the Level I PASRR. Review of records showed the Level I PASRR did not list the schizophrenia diagnosis despite its established onset, and the DON acknowledged it should have been documented. As a result, the required referral for further evaluation by the state-designated authority for major mental illness, intellectual disability, or related conditions was not made.
PASARR services were not properly coordinated or documented for one resident with schizophrenia, anxiety, and bipolar disorder. The PASARR care plan called for group therapy, individual therapy, and routine case management, but the chart lacked documentation of those services, and staff said there was no consistent system to track PASARR visits or records. The facility also did not complete a PASARR Level II reassessment for another resident after a new diagnosis of major depressive disorder was added, even though the MDS nurse said a Form 1012 should have been completed.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
PASARR Level Two Referral Not Acted Upon
Penalty
Summary
The facility failed to ensure a PASARR level two screening referral was acted upon for 1 of 1 resident reviewed for the PASARR screening process. The resident’s quarterly MDS identified diagnoses of disorganized schizophrenia, dementia with behavioral disturbance, developmental disorder of scholastic skills, and metabolic encephalopathy. The resident’s care plan did not identify PASARR level two recommendations. During interview, the DON confirmed a level two screening was not in the resident’s electronic medical record and stated it was important to identify what services were needed. An OBRA Level 1 screening identified serious mental illness and a referral to level two screening with the Hennepin County preadmission screening team, but a policy regarding the PAS process was requested and not received.
Failure to Coordinate PASRR Review for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for one resident who had schizoaffective disorder, bipolar disorder, and anxiety disorder. Record review showed the resident’s quarterly MDS assessment reflected severe cognitive impairment with a BIMS score of 13, and the care plan documented behavior problems related to delusions, hallucinations, and false allegations toward others. The resident’s PASRR Level 1 screening dated 06/18/25 indicated she did not have a mental illness, even though the record also reflected mental illness diagnoses of schizoaffective disorder, bipolar disorder, and anxiety. During interview, the DON stated that if a resident received a new diagnosis, a new PASRR evaluation should be completed, and the Regional MDS Nurse stated the same. The Regional MDS Nurse reviewed the chart and stated the resident did not have a dementia diagnosis and had diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder, but the PASRR Level 1 was negative and did not reflect those mental health diagnoses. She stated she was unable to explain why a new PASRR Level 1 had not been completed when the new diagnoses were found. The ADM stated it was her expectation that the MDS Nurse ensure residents had a PASRR completed prior to admission and that if any resident received a new MI or developmental disability diagnosis while in the facility, the MDS Nurse was responsible for creating a PL1 to submit to the local authorities. Facility policy stated that if a resident had a qualifying MI or ID diagnosis and the nursing facility felt the resident should be positive, the referring entity should be contacted to correct the PL1 or complete the 1012, and that the facility must not accept admission from a hospital without a PL1.
Failure to Ensure Accurate PASRR Screenings and Required Referrals for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that PASRR Level I screenings accurately reflected residents’ mental health status and to coordinate necessary PASRR referrals. For one male resident, the face sheet and MDS documented diagnoses including schizoaffective disorder, depression, generalized anxiety disorder, and insomnia, with an MDS BIMS score indicating no cognitive impairment. His active diagnoses on the MDS included anxiety, depression, and schizophrenia. However, the PASRR Level I screening completed by the referring hospital indicated no primary diagnosis of dementia and no indicator of mental illness, despite the documented schizophrenia diagnosis present on admission. For a female resident, the face sheet and MDS documented diagnoses including depression, vascular dementia with psychotic disturbance, and vascular dementia with anxiety, with an MDS BIMS score indicating no cognitive impairment. Her active diagnoses on the MDS included non‑Alzheimer’s dementia, depression, and schizophrenia. The PASRR Level I screening completed by the referring hospital indicated no indicator of mental illness, and the resident reported she had not received PASRR services. The resident was newly diagnosed with schizophrenia on a later date, but this new diagnosis was not followed by a PASRR Level II referral. Interviews with facility staff confirmed that the PASRR information was inaccurate and that required follow‑up had not occurred. The MDS Coordinator acknowledged that the male resident’s mental illness diagnosis should have resulted in a positive PASRR Level I and that a corrected screening should have been completed and sent to the local authority. The MDS Coordinator also stated she was unaware of the female resident’s new schizophrenia diagnosis and had not notified the local authority as required. The DON and Administrator both stated that the MDS Coordinator was responsible for PASRR accuracy and follow‑through, and that inaccurate PASRR screenings could result in residents not receiving needed services or benefits.
Failure to Document Schizophrenia Diagnosis on PASRR and Refer for Level II Evaluation
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program by not ensuring a resident with a major mental illness was properly identified and referred for further evaluation. Record review showed that one resident, who had multiple diagnoses including a right femur fracture and schizophrenia, had a Level I PASRR dated 3/23/26 that did not document the schizophrenia diagnosis, which had an onset date of 3/21/22. Staff interview on 4/30/26 at 8:45 AM with the DON confirmed that the schizophrenia diagnosis should have been documented on the Level I PASRR but was not, and the resident was therefore not referred for a Level II PASRR evaluation as required for individuals with major mental illness, intellectual disability, or related conditions. This deficient practice was identified for 1 of 3 residents reviewed for Level II PASARR evaluations and was cited as having the potential to cause harm if the resident’s specialized services for mental health needs were not evaluated by the appropriate state-designated authority.
PASARR services and reassessment were not coordinated or documented
Penalty
Summary
The facility failed to coordinate and document PASARR-related services for a resident with serious mental illness. Resident #102 was admitted with schizophrenia, anxiety, and bipolar disorder, had a BIMS score of 15, and his care plan identified a need for specialized services due to mental illness. The PASARR Comprehensive Service Plan meeting documented recommendations for group therapy, individual therapy, and routine case management, but the resident’s electronic record did not contain documentation of those services through the date reviewed. During interviews, the PASARR Case Manager stated she visited the facility monthly to obtain a report from the resident and follow up with nurses, but she did not leave documentation of the visits. The MDS Coordinator stated she was responsible for ensuring PASARR Case Manager visits were conducted, was not aware when the skill trainer visited, and did not coordinate with them after visits. The DON stated he and the corporate nurse would try to obtain evidence of services provided, and the Administrator stated he did not know what services the resident was receiving until surveyor intervention and that there was no system in place to monitor MDS Coordinator oversight of needs. The facility also failed to complete a PASARR Level II assessment for another resident after a new diagnosis of Major Depressive Disorder was added after admission. Resident #86 had diagnoses including hemiplegia/hemiparesis following cerebral infarction, anxiety disorder, and insomnia, and later had Major Depressive Disorder documented on the face sheet. The annual MDS indicated no serious mental illness, and the electronic record did not show a Form 1012 had been completed for the new diagnosis. The MDS Nurse stated she should have completed a Form 1012 for the diagnosis and that she received psychiatric notes by email.
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