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F0645
D

Failure to Complete Required PASARR Assessments for Residents with Mental Health Diagnoses

Tacoma, Washington Survey Completed on 06-12-2025

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 Pre-admission Screening and Resident Review (PASARR) assessments were accurately completed for two residents. For one resident with diagnoses including dementia, depression, and impaired memory, the record showed the resident was unable to make their needs known and was prescribed and administered multiple antidepressant medications. Despite indications for serious mental illness on the Level I PASARR, no Level II referral was completed. Staff interviews confirmed that the PASARR process was missed for this resident, and the lack of a Level II referral did not meet facility expectations. For another resident with multiple health conditions, including anxiety, depression, and PTSD, the Level I PASARR was marked as an exempted hospital discharge, allowing admission without a Level II review. However, the resident remained in the facility longer than 30 days, which should have triggered a correction of the PASARR and a Level II referral. Staff interviews confirmed that this step was not taken. The facility's policy required that all admissions have the appropriate PASARR completed and that state-specific guidelines be followed, but these procedures were not adhered to in these cases.

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