Health inspection·February 19, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of diagnosed mental disorders for 1 (Resident #53) of 6 sampled residents reviewed for PASRR requirements. Residents Affected - Few Findings included: An admission Record revealed the facility admitted Resident #53 on 04/22/2022. According to the admission Record, the resident had admission diagnoses that included depression and post-traumatic stress disorder (PTSD), both with an onset date of 04/27/2022. Resident #53's Preadmission Screening and Resident Review (PASRR) Level I Screening, completed by the Medical Records Director (MRD) on 05/13/2022, indicated the Screening Type was an Initial Preadmission Screening (PAS). Section III - Serious Mental Illness Screen, question 10 was answered no to indicate the resident did not have a diagnosed mental disorder such as depression, anxiety, panic, schizophrenia/schizoaffective disorder, psychotic, delusional, and/or mood disorder. The screening did not reflect the presence of Resident #53's diagnoses of depression or PTSD. As a result, the resident's Level I Screening was negative, and a Level II Evaluation was not required. Resident #53's medical record revealed no documented evidence that the facility had submitted a corrected Level I Screening for the resident. During an interview on 02/19/2025 at 11:07 AM, Medial Records Director (MRD) stated the Minimum Data Set (MDS) nurse was primarily responsible for the accuracy of PASRRs. During an interview on 02/19/2025 at 11:41 AM, MDS Nurse #4 stated Resident #53 had a diagnosis of PTSD when they were admitted to the facility. MDS Nurse #4 further stated that if Resident #53's Level I Screening had accurately reflected the resident's diagnosis of PTSD, it would have required a Level II Evaluation be completed. The Director of Nursing (DON) was interviewed on 02/19/2025 at 2:03 PM. The DON stated she expected staff to review all PASRRs for accuracy. The Administrator was interviewed on 02/19/2025 at 2:11 PM. The Administrator stated they expected PASRRs to be completed accurately. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055003 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055003 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eureka Rehabilitation & Wellness Center, LP 2353 Twenty Third St Eureka, CA 95501 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)