Health inspection·February 27, 2025

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** Based on record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a discharge Minimum Data Set (MDS) accurately reflected the location to which a resident was discharged for 1 (Resident #141) of 27 sampled residents for whom MDS assessments were reviewed. Residents Affected - Few Findings included: A facility policy titled, MDS STANDARD OF PRACTICE, dated 01/2024 indicated, It is the practice of this facility to conduct accurate coding and delivery of services provided to capture accurate assessment of each resident's functional capacity and health status as per CMS RAI MDS 3.0 Manual guidelines. The CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.19.11, dated October 2024, revealed section A2105: Discharge Status specified, Item Rationale - This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. The manual further specified, Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions Select the two-digit code that corresponds to the resident's discharge status. - Code 01, Home/Community: if the resident was discharged to a private home, apartment, board, and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. An admission Record indicated the facility admitted Resident #141 on 01/03/2025. According to the admission Record, Resident #141 was discharged home on [DATE]. Resident #141's Progress Notes revealed a note dated 01/14/2025 at 12:01 PM that indicated the resident was discharged home. Resident #141's [facility name] Notice of Transfer or Discharge, dated 01/14/2025, indicated the resident was discharged home in accordance with their discharge plan. However, Resident #141's discharge, return not anticipated MDS, with an Assessment Reference Date (ARD) of 01/14/2025, revealed the MDS was coded to reflect that the resident was discharged to a short-term general hospital on [DATE]. Page 1 of 3 056116 056116 02/27/2025 Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/27/2025 at 10:35 AM, MDS Coordinator #3 stated that Resident #141 was discharged home on [DATE]. MDS Coordinator #3 stated that Resident #141's discharge MDS, dated [DATE], was incorrectly coded and should have reflected the resident was discharged home, instead of reflecting the resident was discharged to a short-term hospital. During an interview on 02/27/2025 at 11:32 AM, the Director of Nursing (DON) stated she expected MDS assessments to be coded correctly. The DON said Resident #141's discharge MDS should have been coded to reflect that the resident was discharged home and not to a hospital. During an interview on 02/27/2025 at 11:37 AM, the Executive Director (ED) stated he expected MDS assessments to be coded correctly. 056116 Page 2 of 3 056116 02/27/2025 Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illness for 1 (Resident #63) of 4 sampled residents reviewed for PASARR requirements. Residents Affected - Few Findings included: A facility policy titled, Resident Assessment- Coordination with PASARR Program, reviewed/revised on 09/18/2024, 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. An admission Record revealed the facility admitted Resident #63 on 06/12/2021. According to the admission Record, the resident had a medical history that included diagnoses of dementia (onset date of 06/12/2021) and major depressive disorder (onset date of 06/12/2021). Resident #63's Care Plan Report included a focus area, initiated 06/13/2021, that indicated the resident took antidepressant medications related to a diagnosis of depression. Resident #63's Level I PASARR, completed on 06/12/2021, revealed the screening type was an Initial Preadmission Screening (PAS). Section V- Mental Illness of the resident's Level I PASARR was completed in a manner to reflect that the resident did not have a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder, Psychotic/Psychosis, Delusional, Depression, Mood Disorder, Bipolar, or Panic/Anxiety. The Level I PASARR was also completed in a manner to reflect the resident did not have a diagnosis or other evidence of a neurocognitive disorder, including dementia. Resident #63's diagnoses of dementia and major depressive disorder were not reflected. As a result, the resident's Level I PASARR was Negative, due to no mental illness, intellectual disability, developmental disorder, or dementia. During an interview on 02/27/2025 at 10:57 AM, MDS Coordinator #3 stated the importance of Level I PASARRs was to determine if residents required a Level II Evaluation. MDS Coordinator #3 reviewed Resident #63's diagnoses and Level I PASARR, dated 06/12/2021, and stated the resident had diagnoses of depression and dementia when they were admitted to the facility. MDS Coordinator #3 further stated, the resident's Level I PASARR should have been resubmitted because it was not accurate. During an interview on 02/27/2025 at 11:15 AM, the Director of Nursing (DON) confirmed Resident #63 was admitted to the facility with mental health diagnoses and stated the resident's Level I PASARR should have been resubmitted to reflect the presence of the diagnoses. During an interview on 02/27/2025 at 11:37 AM, the Executive Director (ED) stated Resident #63's Level I PASARR was not accurate and should have been resubmitted. 056116 Page 3 of 3