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F0644
D

Failure to Complete Timely PASARR Screenings and Evaluations

Spring Lake, Michigan Survey Completed on 06-13-2025

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 complete an annual Preadmission Screening/Annual Resident Review (PASARR) Level I Screening and Level II Evaluation in a timely manner for a resident with multiple diagnoses, including dementia, depression, and narcissistic personality disorder. The resident's last PASARR Level II Evaluation was completed on 5/15/24, and there was no documentation of a subsequent PASARR Level I Screening or Level II Evaluation being completed as required before 5/15/25. The social worker responsible for tracking PASARR screenings acknowledged that the screening was overdue and had not yet been completed. Record review and staff interviews confirmed that the facility was aware of the overdue PASARR screenings and evaluations, as indicated by the social worker's tracking tool and statements from the nursing home administrator. Although the issue was identified and discussed in the facility's QAPI committee, there was no evidence that corrective actions to address the overdue screenings and evaluations were initiated until the time of the annual survey.

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