MARSHALLTOWN, IA - State health inspectors documented that Southridge Specialty Care failed to update required psychiatric screening documentation after a resident received multiple new mental health diagnoses, a violation that could affect treatment planning and access to specialized services.
Psychiatric Screening Requirements Not Met
During a May 2025 inspection, surveyors identified that facility staff did not update the Preadmission Screening and Resident Review (PASRR) for Resident #19 after the individual received four new psychiatric diagnoses in June 2024. The PASRR is a federally mandated screening tool designed to ensure that individuals with mental illness or intellectual disabilities receive appropriate specialized services in nursing facilities.
The resident's medical record showed four new diagnoses added on June 7, 2024: Major Depressive Disorder with a single episode and moderate severity, Generalized Anxiety Disorder, Bipolar Disorder (unspecified), and Paranoid Personality Disorder. Despite these significant additions to the resident's psychiatric profile, staff did not complete an updated PASRR assessment as required by federal regulations.
The PASRR system serves a critical function in long-term care by identifying residents who may need mental health services beyond what typical nursing facilities provide. When mental health conditions change or new diagnoses are established, facilities must update these screenings to ensure residents have access to appropriate psychiatric treatment, therapy services, and specialized care programs.
Staff Awareness and Communication Gaps
When interviewed by surveyors on May 15, 2025, the facility's Social Services staff member (Staff D) acknowledged that while the team typically shares information about new diagnoses and resident changes during Quality Assurance meetings, PASRR management was relatively new to their role. Staff D confirmed awareness that updating the PASRR following new mental health diagnoses was an expectation but had not completed the required update for this resident.
The Administrator, when interviewed the same day, agreed that staff should have updated the PASRR documentation following the new psychiatric diagnoses. This acknowledgment indicates that facility leadership understood the requirement but that implementation processes had broken down.
Impact on Treatment and Services
Failure to update PASRR screenings when residents receive new mental health diagnoses can have several significant consequences for care delivery. The PASRR process determines whether residents require specialized services that must be provided either within the facility or through external mental health programs. Without current screening information, facilities and state agencies cannot accurately assess what level of psychiatric support a resident needs.
The combination of diagnoses identified in this case—including mood disorders, anxiety, and personality disorders—typically requires coordinated mental health interventions. Major Depressive Disorder and Bipolar Disorder often necessitate careful medication management and monitoring. Generalized Anxiety Disorder may require both pharmaceutical and therapeutic interventions. Personality disorders frequently benefit from specialized behavioral health approaches.
When PASRR documentation remains outdated, there is potential for gaps in service coordination between the nursing facility, mental health providers, and state oversight agencies. The screening helps ensure that Medicaid-certified facilities are appropriate placements for individuals with mental illness and that residents receive necessary specialized services.
Facility Policy Requirements
According to the facility's own policy on Antipsychotic Medication Use, revised in December 2016, staff should evaluate residents who receive antipsychotic medications for appropriateness and indications for use, and complete PASRR screening for individuals with mental illness or intellectual disabilities. This policy establishes the facility's commitment to proper psychiatric assessment and documentation practices.
The policy framework existed to guide staff in maintaining current mental health assessments, yet the system failed to ensure compliance in this instance. The gap between written policy and actual practice suggests a need for strengthened oversight processes and staff education regarding PASRR requirements.
Additional Issues Identified
The inspection documented this violation under federal Tag F644, which addresses the requirement for preadmission screening for mentally ill individuals. Surveyors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Facility Information: - Inspection Date: May 29, 2025 - Facility: Southridge Specialty Care, 309 West Merle Hibbs Boulevard, Marshalltown, IA 50158 - Inspection Type: Health Inspection
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southridge Specialty Care from 2025-05-29 including all violations, facility responses, and corrective action plans.
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