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F0645
D

Failure to Complete and Document Required PASRR Screenings

Baraboo, Wisconsin Survey Completed on 05-13-2025

Penalty

Fine: $19,135
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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 follow the required Preadmission Screening and Resident Review (PASRR) process for two residents. For one resident with diagnoses including dementia, depression, and mood disorder, there was no documentation of a PASRR Level I screening being completed prior to admission, as required by facility policy and Medicaid rules. The social worker confirmed that no PASRR documentation could be found for this resident, indicating that the initial screening step was missed. For another resident with diagnoses such as delusional disorders, restlessness, and agitation, a PASRR Level I was submitted with a 30-day exemption, but there was no documentation of a required PASRR Level II evaluation. The social worker was unable to provide evidence that the Level II evaluation had been completed, and the Director of Nursing confirmed that PASRRs should be completed timely and maintained in the resident's medical record. These lapses demonstrate that the facility did not ensure the appropriate PASRR steps were followed and documented for residents with mental disorders or intellectual disabilities.

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