Failure to Complete PASARR and Notify State Authority After Significant Change in Mental Illness
Summary
The deficiency involves the facility’s failure to complete required PASARR screenings and notify the state authority of significant changes in mental illness for a resident with a 30‑day PASARR exemption. The facility’s policy, revised 1/26, states that all applicants will be screened for serious mental disorders or intellectual disabilities per state Medicaid rules, that residents remaining beyond a 30‑day exemption must receive a Level 1 PASARR and be referred for Level 2 evaluation when indicated, and that any resident with newly evident or possible serious mental disorder or related condition will be referred to the state authority for a Level 2 resident review. The policy also assigns responsibility to the Social Services Director to track each resident’s PASARR status and make referrals. Despite this, a resident admitted with a PASARR dated 10/15/25 and a 30‑day exemption remained in the facility without a new Level 1 PASARR being completed before the exemption expired. Record review showed that the resident’s mental health status changed significantly after admission. A quarterly MDS dated 1/21/26 documented a BIMS score of 3, indicating severely impaired daily decision‑making skills, and a PHQ‑9 score of 13, indicating moderate depressive symptoms. The resident was diagnosed with Unspecified Mood Affective Disorder on 12/9/25 and Adjustment Disorder with Depressed Mood on 2/27/26, and was started on Paroxetine for anger and sexual inappropriateness on 1/8/26, with Depakote Sprinkles and PRN Ativan ordered on 3/27/26 for behaviors. Despite these new psychiatric diagnoses and psychotropic medication changes, the facility did not initiate a new PASARR process or notify the state authority of the significant change in mental illness. During interviews, the Social Services Director stated having nothing to do with processing PASARRs and not knowing who completes new Level 1 PASARRs when residents remain past 30 days or when new diagnoses and medications are added, and the DON confirmed that a new Level 1 PASARR had not been completed when the diagnoses and medications were initiated.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
The facility failed to request Level II PASRR reevaluations for two residents with serious mental illness after significant changes in condition were identified on MDS significant change assessments. Both residents had existing Level II PASRR determinations with no expiration date and were receiving psychotropic medications, yet NC MUST records showed no reevaluation requests following the documented changes. The SW, who was responsible for PASRR submissions, reported being unaware that a significant change in condition required a Level II PASRR reevaluation, and the Administrator confirmed that the SW was designated to review diagnoses and request reevaluations per regulatory guidelines.
Failure to notify the PASRR agency for a Level 2 psychiatric review. A resident admitted with psychotic disorder, hallucinations, Parkinson’s disease, and HTN had a prior Level 1 PASRR showing no psych hx and no need for Level 2 review. Later psych notes identified a psychotic disorder stable on meds, but the SW could not confirm the PASRR agency had been notified for a Level 2 assessment, and the facility only contacted PASRR after surveyor inquiry.
A resident with multiple psychiatric and cognitive diagnoses, including dementia, had an existing PASRR Level II determination and later experienced a significant change in condition, including initiation of hospice care, as documented on a comprehensive MDS and CAA for cognitive loss/dementia. Although the MDS nurse recognized that this resident, listed as a PASRR Level II case, should have been referred for a PASRR re-evaluation after the significant change assessment, no referral was made. The Director of Social Services confirmed she did not submit a PASRR re-evaluation request, stating she believed it was unnecessary because the resident already had a Level II PASRR status, resulting in the facility’s failure to notify the appropriate authorities for a required PASRR Level II re-evaluation.
A resident with a diagnosis of Major Depressive Disorder and a positive Level II PASARR screening did not receive a timely referral for specialized services, as required. Despite recommendations and approvals for therapies, the facility failed to notify the appropriate authorities and initiate PASARR services within the mandated timeframe, as confirmed by staff interviews and record review.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Failure to Request PASRR Level II Reevaluations After Significant Changes in Condition
Penalty
Summary
The facility failed to request Level II PASRR reevaluations after significant changes in condition for residents already determined to have Level II PASRR status. One resident with schizoaffective disorder, bipolar type, and anxiety disorder had a Level II PASRR determination with no expiration date and was identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and schizophrenia, and receiving antipsychotic and antidepressant medications. Despite this significant change assessment, a review of the NC Medicaid Uniform Screening Tool (NC MUST) showed that no PASRR reevaluation request had been submitted following the significant change. Another resident with major depressive disorder and anxiety disorder also had a Level II PASRR determination with no expiration date and was similarly identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and depression and receiving antianxiety and antidepressant medications. NC MUST records again showed no PASRR reevaluation request after the significant change assessment. During interviews, the Social Worker, who was responsible for submitting Level II PASRR reevaluation requests, stated she was still learning the PASRR process and was not aware that a reevaluation request was required when a resident had a significant change in condition. The Administrator confirmed that the Social Worker was responsible for reviewing diagnoses and requesting Level II PASRR reevaluations when residents experienced significant changes in condition per regulatory guidelines.
Failure to Notify PASRR Agency for Level 2 Psychiatric Review
Penalty
Summary
The facility failed to notify the PASRR agency to complete a Level 2 screen for a resident with a psychiatric diagnosis. Resident #2 was admitted from another long-term care facility with diagnoses that included psychotic disorder with hallucinations related to physiological conditions, Parkinson’s disease, and hypertension. A Level 1 PASRR screen transferred with the resident dated 2/1/19 identified no psychiatric history and stated that a Level 2 evaluation was not required. Psychiatric progress notes written by an APRN dated 10/20/25 identified the resident had a psychotic disorder that was stable on current psychiatric medications, while also noting the resident denied psychiatric history despite previous psychiatric diagnoses. During an interview and record review on 1/5/26, the Social Worker was unable to identify that the PASRR agency had been notified to complete a Level 2 assessment for the resident’s psychiatric diagnosis. The Social Worker stated the psychiatric group verbally notifies her when residents develop a new psychiatric diagnosis and that she would be responsible for notifying the PASRR agency, but she was not employed at the facility during that time frame.
Failure to Request PASRR Level II Re-evaluation After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in condition for a resident with a prior Level II PASRR determination. The resident was admitted with multiple psychiatric and cognitive diagnoses, including non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and psychotic disorder, and had a PASRR Level II Determination Notification dated 11/14/23, with a PASRR number ending in H indicating a halted Level II determination due to a primary dementia diagnosis. The resident’s electronic medical record showed a hospitalization and a subsequent significant change comprehensive MDS assessment, which documented that the resident was receiving hospice care. The Care Area Assessment for Cognitive Loss/Dementia also noted that the resident was now under hospice care. The facility’s current list of PASRR Level II residents identified this resident as having Level II status. During interviews, the MDS nurse acknowledged awareness that the resident was a Level II PASRR resident and stated that the resident should have been referred for a PASRR re-evaluation when the significant change MDS was completed, and that the resident had been on the original list of those needing a PASRR referral. However, the MDS nurse did not know whether Social Services had actually made the referral. The Director of Social Services reported that she did not submit a PASRR re-evaluation request for this resident following the significant change MDS, explaining that she believed a referral was unnecessary because the resident already had a Level II PASRR status. As a result, no PASRR Level II re-evaluation was requested despite the documented significant change in the resident’s physical and/or mental status and initiation of hospice care.
Failure to Timely Refer Resident for PASARR Specialized Services
Penalty
Summary
The facility failed to notify the appropriate state mental health or intellectual disability authority promptly after a significant change in the condition of a resident with a mental illness, as required for PASARR (Preadmission Screening and Resident Review) processes. Record review showed that a male resident with a diagnosis of Major Depressive Disorder had a positive Level II PASARR screening and was recommended for specialized services, including physical, occupational, and speech therapy. Despite these recommendations and approvals for services, the facility did not ensure that the resident was referred to PASARR services within the required timeframe. The care plan did not indicate whether the resident received PASARR services, and documentation revealed the resident had been PASARR positive for several years. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, confirmed that the referral for PASARR services was not sent within the required 20-day period following the IDT meeting. Staff acknowledged that this delay or omission could result in the resident not receiving necessary specialized services. Facility policy required notification to the Local Intellectual and Developmental Disability Authority (LIDDA) within two days of admission for positive PASARR screenings, but this process was not followed for the resident in question.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
