Health inspection·October 10, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of a Level I preadmission screening resident review (PASARR) screening for 1 (Resident #74) of 1 sampled resident reviewed for PASARR screening. Residents Affected - Few Findings included: An admission Record indicated the facility admitted Resident #74 on 08/20/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified disorder of psychological development, unspecified psychosis, and depression. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/23/2024, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include depression, psychotic disorder, and unspecified disorder of psychological development. Per the MDS, the resident received an antipsychotic medication during this assessment period. Resident #74's care plan included a focus area initiated 08/20/2024, revealed Resident #74 received Risperdal, an antipsychotic medication. Resident #74's Order Summary Report that contained active orders as of 10/09/2024, revealed an order dated 08/20/2024, for Risperdal oral tablet 1 milligram (mg), give one tablet by mouth at bedtime for unspecified psychosis and risperidone oral tablet 1 mg, give a half a tablet by mouth one time a day for unspecified psychosis. Resident #74's Preadmission Screening and Resident Review Level I Screening dated 08/20/2024, indicated Resident #72 did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusion, and/or mood disturbance. During an interview on 10/10/2024 at 3:26 PM the MDS Coordinator (MDS) stated she was responsible for checking the PASARR for accuracy when residents admitted to the facility. The MDS Coordinator stated a diagnosis of psychosis would be considered a mental illness. The MDS Coordinator stated Resident #74 received an antipsychotic medication and had a diagnosis of psychosis and the resident's mental illness diagnosis should have been indicated on the Level I PASARR screening. During an interview on 10/10/2024 at 9:16 AM the Director of Nursing (DON) stated her expectation was that the PASARR screening was completed. According to the DON, the MDS Coordinator followed up after a resident's admission to ensure the PASARR was completed accurately. The DON stated she thought Page 1 of 4 055276 055276 10/10/2024 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #74 had a mental illness diagnosis. The DON stated if the Level I screening was not accurate, no one would complete a Level II review, and the facility would not know what services were available for Resident #74. In an interview on 10/10/2024 at 10:02 AM, the Administrator stated his expectation was that the PASARR was completed timely and the MDS Coordinator verified that the PASARR for accuracy. A facility policy titled admission Criteria, revised 03/2023, indicated 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy indicated b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 055276 Page 2 of 4 055276 10/10/2024 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 8 (Rooms 27 - 34) of 13 residents' rooms on 1 (Station 3) of 3 units in the facility. Findings included: On 10/10/2024 at 8:28 AM, the Maintenance Director measured the following rooms and confirmed the following dimensions: In room [ROOM NUMBER], there was 70 sq feet for resident. In room [ROOM NUMBER], there was 70 sq ft for each resident. In room [ROOM NUMBER], there was 70 sq ft for each resident. In room [ROOM NUMBER], there was 70 sq ft for each resident. In room [ROOM NUMBER], there was 70 sq ft for each resident. In room [ROOM NUMBER], there was 70 sq ft for each resident. In room [ROOM NUMBER], there was 78.75 sq ft for each resident. In room [ROOM NUMBER], there was 75sq ft for each resident. During an interview on 10/10/2024 at 9:40 AM, Certified Nursing Assistant (CNA) #1, stated she had no problems with providing care due to a resident's room size. During an interview on 10/10/2024 at 9:42 AM, CNA #2 stated she had no issues with providing care 055276 Page 3 of 4 055276 10/10/2024 Mission Valley Post Acute 2400 Parkside Drive Fremont, CA 94536

F 0912 due to a resident's room size. Level of Harm - Potential for minimal harm During an interview on 10/10/2024 at 9:45 AM, Licensed Vocational Nurse #3 stated she never had an issue providing care due to a resident's room size. Residents Affected - Some During an interview on 10/10/2024 at 10:09 AM, the Administrator stated he was aware of the room size requirements. The Administrator stated it was important for resident rooms to be a certain size so staff could provide care for the resident and for the size of the room to not impede the care provided. During an interview on 10/10/2024 at 10:19 AM, the Director of Nursing (DON) stated she thought the minimum resident room size requirements were 80 to 100 sq ft. The DON stated she expected the facility to meet whatever the regulation was regarding resident room sizes. 055276 Page 4 of 4