Health inspection·April 25, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #9's admission Record revealed the facility admitted the resident on 09/23/2022 with diagnoses to include dependence on supplemental oxygen, chronic obstructive pulmonary disease, schizophrenia, major depressive disorder, and anxiety disorder. Residents Affected - Few A review of Resident #9's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2024, revealed the resident was not currently considered by the state level II PASARR to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 04/25/2024 at 8:57 AM, the Registered Nurse (RN) MDS Coordinator stated she was ultimately responsible to ensure the accuracy of the MDS assessments. The RN MDS Coordinator stated accuracy of the MDS was important for billing purposes and it ensured the facility provided the best care possible. The RN MDS Coordinator stated Resident #9's MDS was incorrect as the resident had a serious mental illness. During an interview on 04/25/2024 at 9:36 AM, the Director of Nursing (DON) stated the RN MDS Coordinator was responsible to ensure the accuracy of the MDS assessment. Per the DON, the accuracy of the MDS was important not only for billing but to ensure residents received the type of care they needed. The DON stated the MDS should accurately reflect the resident's PASARR status. During an interview on 04/25/2024 at 9:46 AM, the Administrator stated the accuracy of the MDS was important to ensure the facility provided all the care and services that the resident required. Based on record reviews, interviews, and facility policy review, the facility failed to ensure the Minimum Data Set assessments were accurate for 2 (Resident #9 and Resident #147) of 29 sampled residents. Specifically, the facility incorrectly coded Resident #147 being discharged to the hospital instead of home and did not accurately code Resident #9's level II preadmission screening and resident review (PASARR) status. Findings included: A review of the facility policy titled, MDS 3.0 Completion, implemented on 12/19/2022, revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy revealed, Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident' functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. (continued on next page) 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 4 Event ID: 055409 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 055409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care and Rehabilitation Center 4070 Jurupa Avenue Riverside, CA 92506 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)