Health inspection·November 21, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #65 and Resident #72) of 19 sampled residents. Residents Affected - Few Findings included: During an interview on 11/20/2024 at 10:16 AM, the Director of Nursing (DON) indicated the facility did not have a policy on MDS accuracy. 1. An admission Record revealed the facility admitted Resident #72 on 10/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. An admission MDS, with an Assessment Reference Date (ARD) of 10/19/2024, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed that the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. A letter from the California Department of Health Care Services, dated 09/26/2024, revealed a Level II evaluation was conducted on 09/26/2024 and specialized services were recommended. During an interview on 11/21/2024 at 8:43 AM, the MDS Coordinator stated she reviewed the electronic and paper chart, observed the resident, and interviewed the resident and staff to complete an accurate MDS. The MDS Coordinator indicated that to complete the admission MDS she reviewed the hospital documentation and the resident's history and physical. During an interview on 11/21/2024 at 9:35 AM, the DON stated she expected for the MDS to be accurate. The DON stated it was important for information to be true and accurate because the MDS needed to reflect the actual state of the resident. During an interview on 11/21/2024 at 9:54 AM, the MDS Coordinator stated Resident #72's PASRR Level II was missed and should have been coded on the resident's admission MDS. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated he expected the MDS to be completed accurately and in a timely manner. The Administrator stated it was important to capture the correct information so the MDS would be accurate. 2. An admission Record indicated the facility admitted Resident #65 on 07/02/2024. According to the Page 1 of 6 055510 055510 11/21/2024 Redding Post Acute 1836 Gold Street Redding, CA 96001

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, chronic peptic ulcer, and hypertension. An admission MDS, with an Assessment Reference Date (ARD) of 07/09/2024, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Per the MDS, Resident #65 did not use tobacco at the time of the assessment. Resident #65's care plan included a focus area initiated 09/19/2024 that indicated the resident was a smoker. Interventions directed staff to educate the resident regarding the facility's smoking policy, designated smoking areas, and the storage of smoking materials. Resident #65's Progress Notes dated 07/02/2024 indicated the resident was a current smoker and was interested in the facility smoking schedule. During an interview on 11/20/2024 at 8:50 AM, Resident #65 stated they had been a smoker since before admission to the facility. During an interview on 11/21/2024 at 8:43 AM, the MDS Coordinator stated she reviewed the resident's chart and interviewed staff and the resident when completing their MDS. The MDS Coordinator further stated she thought when she interviewed Resident #65 upon admission that they were not smoking, but the resident was in fact smoking with the activities department. During an interview on 11/21/2024 at 9:35 AM, the DON stated she expected the MDS to be completed to accurately reflect the resident's status to ensure facility staff provided the appropriate care for each resident. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated he expected the MDS to be completed accurately and in a timely manner. 055510 Page 2 of 6 055510 11/21/2024 Redding Post Acute 1836 Gold Street Redding, CA 96001

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident who received a psychiatric diagnosis, prior to readmission, for 1 (Resident #16) of 3 residents reviewed for PASRR. Findings included: An undated facility policy titled, PASRR Completion Policy revealed, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An admission Record revealed the facility originally admitted Resident #16 on 01/10/2024 and re-admitted the resident on 08/01/2024. According to the admission Record, the resident had a medical history that included diagnosis of dementia with behavioral disturbance. A Medicare 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active psychiatric diagnoses of anxiety and psychotic disorder. Per the MDS, the resident received antipsychotic and antianxiety medication during the assessment timeframe. Resident #16's care plan included a focus area revised on 01/29/2024, that indicated the resident had the potential to be physically aggressive towards staff. Interventions directed staff to analyze the time of day, place, circumstances, triggers, and what de-escalates the behavior (initiated 01/29/2024); to assess and address for contributing sensory deficits (initiated 01/29/2024); and when the resident becomes agitated, intervene before agitation escalates (initiated 01/29/2024). The care plan included a focus area initiated on 06/07/2024, that indicated the resident used psychotropic medications related to psychosis, as evidenced by verbal and physical aggression, sexual outbursts, and the inability to redirect. Interventions directed staff to administer psychotropic medications as ordered by the physician, and to monitor for side effects and effectiveness (initiated 06/07/2024). Resident #16's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 12/28/2023, prior to Resident #16's first admission to the facility, indicated the resident did not have a serious diagnosed mental disorder. The Level I Screening indicated a Level II Mental Health Evaluation was not required. Resident #16's Census List, dated 11/19/2024, revealed Resident #16 was transferred to the hospital on [DATE] and discharged from the facility after seven days, on 07/19/2024. The Census List further revealed Resident #16 was re-admitted to the facility on [DATE]. An IDT [Interdisciplinary Team] Review note dated 07/11/2024 revealed Resident #16 was sent to a facility for psychiatric care for two to four weeks because of aggressive behaviors and would return to the facility when completed. A General Note dated 08/02/2024 revealed Resident #16 arrived back at the facility and was adjusting well. 055510 Page 3 of 6 055510 11/21/2024 Redding Post Acute 1836 Gold Street Redding, CA 96001

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A hospital Discharge Summary dated 08/01/2024, revealed Resident #16 had a new diagnosis of unspecified psychosis, in addition to an existing diagnosis of dementia with behavioral disturbance. Resident #16's medical record revealed no other PASRR had been completed since re-admission to the facility on [DATE], and no evidence that indicated a referral was made to the appropriate state-designated authority after receiving a new psychiatric diagnosis. During an interview on 11/20/2024 at 10:16 AM, the Director of Nursing (DON) stated a new PASRR should have been completed when Resident #16 was readmitted to the facility in August 2024. During a subsequent interview on 11/20/2024 at 11:15 AM, the DON stated she was going to have the Social Services Director (SSD) submit a new Level I Screening, as it should have been done when the resident returned from a psychiatric stay with a diagnosed mental illness of psychosis. During an interview on 11/21/2024 at 8:23 AM, the SSD stated the Level I Screening was to be completed at the hospital prior to a resident's admission to the facility, and the Business Office Manager (BOM) would make sure the paperwork was present prior to admission. During an interview on 11/21/2024 at 8:27 AM, the BOM stated the hospital completed the PASRR prior to a resident coming to a skilled nursing facility. The BOM stated that the accuracy of the PASRR was assessed by the DON, and if the resident had an issue with mental illness after admission, the facility would initiate an additional PASRR. She also stated if the resident triggered a positive Level I PASRR and required a Level II assessment, both should be completed at the hospital prior to admission. During an interview on 11/21/2024 at 8:32 AM, the DON stated all admissions were reviewed for medications and diagnoses that would trigger a positive Level I PASRR prior to admission. She stated the Admissions Director would bring the PASRR to her to review if it did not match the diagnoses available in the resident's medical history. The DON stated that if the PASRR was incorrect, the facility would notify the hospital's PASRR department so they could educate their team on what was incorrect. The DON stated there was a lack of training regarding Resident #16's PASRR. The DON stated the facility Resident #16 was sent to for psychiatric inpatient care did not participate in the PASRR program and did not complete a Level I assessment prior to discharge. She stated it was the responsibility of the facility to complete the Level I PASRR when the resident returned. The DON stated they should have completed another assessment for Resident #16, and the facility would start the assessment process. The DON stated her expectation going forward was for the PASRR to be reviewed by the Admissions Director, who is a nurse, prior to admission. The DON stated if there was a question or concern regarding a medication or diagnosis, she could get clarification. She stated she reviewed admissions as well and corrected or initiated a new PASRR if needed and notified the hospital of errors. The DON stated the PASRR system needed work and more training so the facility could have a good and functioning PASRR program. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated the PASRRs should come from the hospital, and if a Level II was needed, it should happen at the hospital prior to admission. He stated the PASRRs needed to be accurate with proper psychiatric diagnoses and he would defer to the DON on the importance of the PASRR process. 055510 Page 4 of 6 055510 11/21/2024 Redding Post Acute 1836 Gold Street Redding, CA 96001

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, facility document review, and facility policy review, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for 1 (Resident #24) of 3 residents reviewed for PASRR. Specifically, Resident #24 had a diagnosis of schizophrenia that was not captured on their Level I PASRR. Residents Affected - Few Findings included: An undated facility policy titled, PASRR Completion Policy, indicated, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An admission Record indicated the facility admitted Resident #24's on 06/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia with an onset date of 06/03/2024 and major depressive disorder with an onset date of 06/03/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #24 was not considered by the state Level II PASARR process to have a serious mental illness. Resident #24's care plan included a focus area initiated on 06/03/2024 that indicated the resident used psychotropic medications related to schizophrenia as evidenced by auditory hallucinations. Interventions directed staff to monitor for any adverse reactions of psychotropic medications and to monitor and record the occurrence of target behavior symptoms. Resident #24's Order Summary Report contained an order dated 08/24/2024, for Aripiprazole (antipsychotic) oral tablet 30 milligrams (mg) with instructions to give 30 mg by mouth one time a day as evidenced by auditory hallucinations related to schizophrenia. Resident #24's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/03/2024, indicated the resident had a serious diagnosed mental disorder of depression. The screening revealed schizophrenia was not listed as a diagnosed mental disorder. Services dated 06/03/2024 indicated the state was unable to complete a Level II evaluation because Resident #24 had no serious mental illness. During an interview on 11/21/2024 at 8:24 AM, the Social Services Director (SSD) stated the Level I PASRR was completed at the hospital prior to admission. During an interview on 11/21/2024 at 8:25 AM, the Business Office Manager (BOM) stated the hospital completed the Level I PASRR and the Director of Nursing (DON) was responsible for ensuring the accuracy of these screenings. The BOM further stated the facility accepted the hospital-completed Level I PASRR for admission. During an interview on 11/21/2024 at 8:32 AM, the DON stated the BOM had access to the PASRR screening system, and she reviewed them prior to a resident's admission for accuracy. The DON further stated Resident #24's schizophrenia diagnosis was not listed on their Level I PASRR and that it needed 055510 Page 5 of 6 055510 11/21/2024 Redding Post Acute 1836 Gold Street Redding, CA 96001

F 0645 to be redone and resubmitted to include that diagnosis. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/21/2024 at 10:06 AM, the Administrator stated that Level I PASRRs were completed at the hospital prior to admission, and they needed to accurately reflect a resident's mental health diagnosis. Residents Affected - Few 055510 Page 6 of 6