Health inspection·December 1, 2023

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Review (PASARR) was accurately completed upon admission for 1 (Resident #36) of 3 sampled residents reviewed for PASARRs. Residents Affected - Few Findings included: Review of a facility policy titled, Resident Assessment- Coordination with PASARR Program, revised in 10/31/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. A review of Resident #36's admission Record revealed the facility admitted the resident on 03/16/2021. A review of Resident #36's hospital Discharge Referral, with a hospital admission date of 03/11/2021, revealed the resident had a diagnosis of unspecified psychosis with an onset date of 08/08/2019. A review of Resident #36's Preadmission Screening and Resident Review Level I Screening, dated 03/17/2021, indicated Resident #36 did not have a diagnosed mental disorder such as depression, anxiety, panic, schizophrenia/schizoaffective disorder, psychotic, delusional, ad/or mood disorder. A review of Resident #36's care plan, initiated 03/26/2021, indicated Resident #36 had a behavior problem due to manic episodes as evidence by aggression, throwing objects, psychosis, hallucinations, hypervigilance, and verbal aggression. A review of Resident #36's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2023, revealed Resident #36 had an active diagnosis to include unspecified psychosis. A review of Resident #36's Order Summary Report with active orders as of 11/29/2023, revealed an order dated 03/23/2023 for haloperidol 5 milligrams, one tablet by mouth one time a day for unspecified psychosis, hallucinations, hyper vigilance, and verbal aggression. During an interview on 11/30/2023 at 3:18 PM, the Admissions Director (AD) revealed a PASARR was checked for accuracy by looking over the physician's orders and the history and physical. The AD added Resident #36's psychosis diagnosis should have absolutely been on the resident's PASARR. During an interview with the Director of Nursing (DON) and the Executive Director on 12/01/2023 at Page 1 of 2 055797 055797 12/01/2023 Gilroy Healthcare Center 8170 Murray Avenue Gilroy, CA 95020

F 0645 9:51 AM, they revealed Resident #36's diagnosis of psychosis should have been on the resident's PASARR upon admission. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055797 Page 2 of 2