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F0641
D

Inaccurate MDS Assessments for PASRR Level II Status

Sandpoint, Idaho Survey Completed on 07-25-2025

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 the Minimum Data Set (MDS) assessments for two residents accurately reflected their PASRR (Preadmission Screening and Resident Review) Level II status, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with diagnoses including schizophrenia, anxiety, and depression, the PASRR Level II screening documented a primary diagnosis of schizophrenia with medication management. However, the resident's Annual MDS assessment incorrectly indicated that a PASRR Level II had not been completed. The MDS Coordinator confirmed that this was inaccurate and that the assessment should have been marked as completed. Similarly, another resident with diagnoses of bipolar disorder and depression had a PASRR Level II screening confirming these conditions and ongoing medication management. Despite this, the resident's Annual MDS assessment was also inaccurately coded as not having a PASRR Level II evaluation. The MDS Coordinator acknowledged the error upon review. These inaccuracies were identified through record review and staff interviews.

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