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F0644
E

Failure to Complete and Implement PASRR Evaluations and Recommendations

Everett, Washington Survey Completed on 07-21-2025

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 proper coordination and completion of the Preadmission Screening and Resident Review (PASRR) process for four out of six residents reviewed. Specifically, residents with diagnoses including depression, major depressive disorder, anxiety disorder, dementia, and borderline personality disorder were either not referred for required Level II PASRR evaluations or had recommendations from completed Level II evaluations omitted from their care plans. Documentation showed that Level I PASRR screenings indicated the need for Level II evaluations for several residents, but there was no evidence that these evaluations were completed or that the state PASRR evaluator was contacted as required. For one resident with a diagnosis of depression, the Level I PASRR indicated a need for a Level II evaluation, but no such evaluation was found in the electronic health record, and the state PASRR evaluator confirmed no referral was received. Another resident with major depressive disorder also required a Level II evaluation, but staff could not locate documentation of its completion. A third resident with dementia, anxiety disorder, and depression had an invalidated Level II PASRR and, after a repeat Level I PASRR, again required a Level II evaluation, but there was no documentation of follow-up or communication with the state evaluator. A fourth resident with depression and borderline personality disorder had a completed Level II PASRR evaluation with specific recommendations for care, including environmental modifications and trauma-informed approaches. However, none of these recommendations were incorporated into the resident's care plan, and staff were unaware of the evaluation's findings or the resident's trauma history. Interviews with staff revealed a lack of awareness and follow-through regarding PASRR requirements and care plan updates, and management was unaware of the deficiencies until informed during the survey.

See complete original report
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