Health inspection·May 8, 2025

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. Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASRR) when the resident was diagnosed with a new mental illness diagnosis for 1 (Resident #134) of 3 sampled residents reviewed for PASRR. Findings included: An undated facility policy titled, PASRR (Pre-admission Screening & Resident Review), indicated, To ensure each patient in the facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. An admission Record indicated the facility admitted Resident #134 on 01/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of generalized anxiety disorder and post-traumatic stress disorder. Per the admission Record, the resident received a diagnosis of major depressive disorder on 04/14/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2025, revealed Resident #134 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS revealed the resident had active diagnoses to include anxiety disorder and post-traumatic stress disorder. Resident #134's medical record revealed no evidence to indicate a level II PASRR was resubmitted after the resident was diagnosed with major depressive disorder on 04/14/2025. During an interview on 05/07/2025 at 9:55 AM, the Admissions Director stated if a resident had a change in condition or if a new diagnosis or psychiatric medication was added, the facility completed another PASRR for the resident. Per the Admissions Director, the Director of Nursing (DON) was responsible for completing the PASRR screening. The Admissions Director stated that she checked the PASRR portal and Resident #134's most recent PASRR was completed in January 2025. During an interview on 05/07/2025 at 3:22 PM, the MDS Coordinator stated the facility should have identified that Resident #134's diagnosis of major depressive disorder was not on the resident's level I screening and another screening should have been completed. During an interview on 05/07/2025 at 2:47 PM, the DON stated if she had noticed that the resident's depression diagnosis was not listed on the initial PASRR, another PASRR should have been completed. (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 6 Event ID: 055806 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 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)