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F0645
D

Failure to Complete and Follow Up on PASRR Assessments for Residents with Mental Illness

Cheney, Washington Survey Completed on 08-20-2025

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 completion and follow-up of Pre-admission Screening and Resident Review (PASRR) processes for three residents with mental health diagnoses. For one resident with depression and anxiety, a Level I PASRR screening was completed prior to admission but incorrectly documented that there was no serious mental illness, and no Level II evaluation was initiated. Another resident, who was initially exempt from a Level II evaluation due to an expected short stay, remained in the facility beyond the exemption period without a subsequent referral for a Level II assessment, and there was no documentation from facility management or the social worker regarding this oversight. A third resident with a history of depression and changes in psychotropic medication had a Level I PASRR completed after medication adjustments, which indicated serious mental illness indicators in one section but contradicted this in another section, resulting in no Level II evaluation being conducted. Interviews with facility staff confirmed that the required PASRR processes were not followed, including the need for timely and accurate assessments and referrals for Level II evaluations when indicated.

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