Eagle Rock Health: PTSD Screening Failures - ID

Eagle Rock Health and Rehabilitation of Cascadia admitted the resident on March 3 but failed to document his PTSD diagnosis on the initial screening form that determines whether patients need deeper psychiatric evaluation. The facility's own medical records clearly listed his chronic post-traumatic stress disorder the same day he arrived.

Federal inspectors discovered the violation during an April 2 review of the facility's pre-admission screening procedures. The resident, identified as Resident #13 in the inspection report, was readmitted to the facility after joint replacement surgery but carried multiple diagnoses including his psychiatric condition.

The Pre-admission Screening and Resident Review process, known as PASRR, serves as a gatekeeper for specialized mental health services in nursing homes. A Level I screening flags residents who might need psychiatric care. Those who screen positive must receive a more comprehensive Level II evaluation before admission.

Eagle Rock's own policy, dated August 29, 2025, required staff to complete Level I screenings before admission and obtain Level II evaluations when warranted. The policy stated that positive Level I screens "necessitates an in-depth evaluation of the individual by the state-designated authority."

But Resident #13's Level I screening forms from March 3 and March 13 contained no mention of his post-traumatic stress disorder or anxiety disorders. Both conditions should have triggered the more extensive evaluation process.

The facility scrambled to correct the oversight only after inspectors arrived. On March 30, nearly four weeks after admission, staff finally completed the Level II screening and faxed it to the state mental health authority for review.

The Resident Support Services Assistant told inspectors on March 31 that the Level II evaluation had "just been completed" the previous day. By then, the resident had been living in the facility for 27 days without the specialized mental health assessment required by his psychiatric diagnosis.

The inspection report classified the violation as causing "minimal harm or potential for actual harm" but noted it affected the facility's ability to provide appropriate specialized services. Federal regulations require nursing homes to identify residents who need psychiatric care and ensure they receive it.

Post-traumatic stress disorder can significantly impact a nursing home resident's daily life, affecting sleep patterns, social interactions, and responses to medical procedures. Specialized services might include trauma-informed care approaches, psychiatric medication management, or counseling services tailored to PTSD symptoms.

The screening failure represented a breakdown in the facility's admission process. Staff documented the resident's PTSD diagnosis in his medical record on the day he arrived but somehow failed to transfer that critical information to the screening forms designed to identify residents needing mental health services.

Eagle Rock's violation highlights a broader challenge in nursing home care: ensuring residents with psychiatric conditions receive appropriate specialized services. The PASRR system was created specifically to prevent warehousing of individuals with mental illness in facilities unprepared to meet their needs.

The resident's case involved a readmission, suggesting staff had previous knowledge of his medical history and diagnoses. Yet the screening forms completed during both March admissions omitted the psychiatric conditions that would have mandated additional evaluation.

Federal inspectors found that as of March 30, the resident's medical record contained no documentation that the required Level II screening had been completed. Only the urgent completion and faxing of forms after inspectors' arrival brought the facility into compliance.

The violation occurred despite the facility's written procedures clearly outlining the screening requirements. Staff knew the process but failed to execute it properly, leaving a vulnerable resident without access to specialized mental health services for nearly a month.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Eagle Rock Health and Rehabilitation of Cascadia from 2026-04-02 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Eagle Rock Health and Rehabilitation of Cascadia
• Browse all ID nursing home inspections