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F0645
D

Failure to Complete PASRR Assessment After Change in Condition

Clovis, California Survey Completed on 04-04-2025

Penalty

No penalty information released
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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 a Level I Preadmission Screening and Resident Review (PASRR) was completed accurately for a resident who was admitted for hospice care. The resident, who had diagnoses including Parkinson's Disease, hypothyroidism, and dementia, was admitted and later readmitted to the facility. Upon review, it was found that the most recent PASRR assessment on file was dated several months prior to the resident's admission to hospice care, and no updated PASRR was completed at the time of this significant change in condition. Interviews with facility staff, including the Minimum Data Set Nurse (MDSN), Administrator, and Director of Nursing (DON), confirmed that it was the facility's practice and policy to complete a PASRR assessment annually, upon a change of condition, and when a resident is admitted to hospice care. The MDSN acknowledged that the assessment should have been completed at the time of hospice admission but was not. Facility documentation also indicated that a Resident Review PASRR should be conducted for significant changes in condition, which did not occur in this case.

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