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F0645
D

Failure to Accurately Complete PASRR Assessments for Residents with Mental Illness

Woodland, Washington Survey Completed on 06-20-2025

Penalty

23 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 ensure that the Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected mental health diagnoses for two residents. For one resident admitted with a diagnosis of depressive disorder and documented as severely cognitively impaired, the admission PASRR Level I did not indicate the presence of major depressive disorder. A repeat PASRR Level I later documented depressive disorder but did not clarify whether a PASRR Level II evaluation was indicated. For another resident admitted with diagnoses including post-traumatic stress disorder, anxiety disorder, and major depressive disorder, the admission PASRR Level I noted serious mental indicators but did not require a Level II evaluation due to an exempted hospital discharge. A subsequent PASRR Level I again documented serious mental illness but lacked documentation regarding the need for a Level II evaluation. During interviews, the Social Services Director acknowledged that both residents had serious mental illnesses prior to admission and that the PASRR Level I screenings were completed incorrectly at admission and upon repeat. The lack of accurate and complete PASRR documentation resulted in the failure to properly identify and address the residents' mental health needs as required.

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