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F0645
D

Failure to Complete Required PASRR Level II Evaluation Prior to Admission

Cheyenne, Wyoming Survey Completed on 11-18-2025

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

A deficiency was identified when a resident was admitted to the facility without completion of a required Level II PASRR (Preadmission Screening and Resident Review) evaluation. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had documented diagnoses including bipolar disorder, anxiety disorder, and a history of cerebrovascular accident, transient ischemic attack, or stroke. Review of the resident's PASRR Level I screening indicated the presence of a mental illness that necessitated a Level II PASRR evaluation prior to admission. However, medical record review and staff interview confirmed that this evaluation was not completed before the resident's admission.

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