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F0645
E

Failure to Complete Timely PASARR Screenings Prior to Admission

Randolph, Massachusetts Survey Completed on 08-14-2025

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 accurately complete Level I Pre-admission Screening and Resident Review (PASARR) for three residents prior to or upon admission. For one resident with diagnoses including adjustment disorder and dementia, the Level I PASARR was not completed until after admission, as confirmed by the Admissions Coordinator. Another resident with a diagnosis of paranoia was admitted without the Level I PASARR being completed at the appropriate time, and the staff member responsible for the form did not identify the resident's documented diagnosis of paranoia. In both cases, the PASARR was submitted only after the residents had already been admitted. A third resident, admitted with diagnoses of post-traumatic stress disorder, agoraphobia, and substance use disorder, also did not have a Level I PASARR completed at or before admission. This issue was identified during an internal audit, and the PASARR was subsequently completed and submitted. The failure to complete the required PASARR screenings prior to or upon admission resulted in these residents being admitted without a determination of whether they screened positive for intellectual disability, developmental disability, or serious mental illness requiring further evaluation.

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