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F0645
E

Incomplete and Inaccurate PASRR Documentation for Multiple Residents

Pt Orchard, Washington Survey Completed on 04-28-2025

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 Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for four out of seven sampled residents. For one resident with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis, the PASRR Level I forms did not consistently reflect all current diagnoses, and a Level II evaluation was not completed despite changes in the resident's condition. Staff acknowledged that a new referral was not sent and that errors in the PASRR documentation were not corrected in a timely manner. Another resident with diagnoses of PTSD, major depressive disorder, anxiety disorder, and schizoaffective disorder had a PASRR Level I that failed to indicate any serious mental illness, which staff later confirmed was incorrect. Additional residents with diagnoses such as major depressive disorder, unspecified dementia, and anxiety disorder also had PASRR Level I forms that omitted relevant diagnoses. Staff interviews confirmed that these omissions were recognized but not addressed at the time, resulting in incomplete and inaccurate PASRR documentation for multiple residents.

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