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F0645
E

Delayed and Incomplete PASARR Screenings for Residents with Mental Health Diagnoses

Puyallup, Washington Survey Completed on 09-15-2025

Penalty

3 days payment denial
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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 promptly complete the Preadmission Screening and Resident Review (PASARR) for four out of seven sampled residents with mental health diagnoses or intellectual disabilities. For these residents, the PASARR Level 1 screenings were not conducted within the expected timeframe after admission, with delays ranging from 15 days to over four months. The residents involved had diagnoses such as dementia, depression, psychotic disorder, hemiplegia, diabetes, arthritis, bipolar disorder, and heart failure, and were able to communicate their needs. The records showed that the PASARR screenings were either significantly delayed or, in one case, a required Level 2 evaluation referral for mental illness was not made. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the PASARR screenings for these residents were not completed in a timely manner and did not meet facility expectations. The Director of Nursing Services also acknowledged that the lack of a Level 2 evaluation referral for a resident with mental illness was not in accordance with expectations. These findings were based on review of electronic health records and staff interviews, as referenced under WAC 388-97-1915(1)(2)(a-c).

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