Health inspection·October 3, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An admission Record indicated the facility admitted Resident #42 on 08/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia and severe major depressive disorder with psychotic symptoms. Residents Affected - Some An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident had active diagnoses to include depression and schizophrenia. A typed document from the California Department of Health Care Services dated 08/04/2024, indicated a Level II mental health evaluation was not required due to an Exempted Hospital Discharge. According to the document, if Resident #42 remained in the nursing facility longer than 30 days, the facility must resubmit a new Level I screening on the 31st day. Resident #42's medical record revealed no documented evidence the facility submitted a new Level I screening for the resident on the 31st day after admission to the facility. During an interview on 10/02/2024 at 1:52 PM, the MDS Coordinator stated he was not aware he should resubmit a Level I screening within certain times frames. The MDS Coordinator acknowledged a Level I screening was not resubmitted for Resident #42. During an interview on10/02/2024 at 2:15 PM, the Director of Nursing (DON) stated she was not involved in the PASARR process. The DON stated she expected PASARR screenings to be completed accurately and submitted/resubmitted timely. During an interview on 10/02/2024 at 2:24 PM, the Administrator stated she was not involved in the PASARR process, but expected PASARR screenings to be completed accurately and timely. Based on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PAASRR) screening was completed prior to admission to the facility for 3 (Residents #22, #42, and #86) of 5 sampled residents reviewed for PASARR screening. Findings included: A facility policy titled, Pre-admission Screening Resident Review Level I, revised10/2018, specified, Policy: The State of California has adopted a process to submit Pre-admission Screening Resident Review electronically. All facilities must complete the [PASARR] by midnight of the date of Page 1 of 3 056136 056136 10/03/2024 Villa Mesa Care Center 867 E. 11th St Upland, CA 91786

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission. The policy revealed IX. The BOM [Business Office Manager] will review the status of [PASARR] daily before Stand-Up Meeting to review if new admissions' [PASARR] have been completed. X. The BOM will report during Stand-Up Meeting the status of the [PASARR(s)]. The policy indicated, XII. The admission Coordinator/Case Manager will ensure that the [PASARR] is part of the admission mini packet. XIII. The facility Administrator will ensure any incomplete [PASARR(s)] are completed that day. If the person who initiated the [PASARR] is not there the following date to complete it, it must be completed by a [PASARR] Administrator. According to the policy, XV. The Medical Records admission Audit will include [PASARR] completion. 1. An admission Record revealed the facility admitted Resident #22 on 07/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, post-traumatic stress disorder (PTSD), and anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, revealed Resident #22 had Brief Interview for Mental Status (BIMS) Score of 13, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include anxiety disorder, schizophrenia, and PTSD. Resident #22's Patient Care Plan: Anxiety included a problem/need statement dated 07/01/2024, that indicated the resident had behaviors of anxiety due to diagnoses of schizoaffective disorder and PTSD that manifested by rapid mood changes. Resident #22's medical record revealed no documented evidence the facility completed a Level I PASARR Screening prior to admission of the resident to the facility. During an interview on 10/01/2024 at 11:14 AM, the MDS Coordinator stated the resident's PASARR was never transferred from their previous facility, and the facility never received a PASARR for Resident #22. 2. An admission Record revealed the facility admitted Resident #86 on 08/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and anxiety disorder. An admission [NAME] Data Set (MDS), with an Assessment Reference Date (ARD) of 08/30/2024, revealed Resident #86 had Brief Interview for Mental Status (BIMS) Score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression, and schizophrenia. Resident #86's care plan included a problem/need statement dated 08/27/2024, that indicated the resident had schizophrenia. The care plan revealed the goal was for the resident to receive specialized services as recommended by a Level II determination evaluation report as indicated and coordinated by the interdisciplinary team. Resident #86's Preadmission Screening and Resident Review Level I Screening, dated 07/10/2024, revealed Resident #86 had diagnosis of dementia psychosis and had been prescribed Seroquel. The Level I PASARR screening revealed the resident was positive for a serious mental illness and a Level II screening was required. Resident #86's medical record revealed no evidence to indicate a Level II screening was conducted. 056136 Page 2 of 3 056136 10/03/2024 Villa Mesa Care Center 867 E. 11th St Upland, CA 91786

F 0645 During an interview on 10/01/2024 at 10:20 AM, the MDS Coordinator stated he did not ensure a new PASARR for Resident #86 was submitted. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 056136 Page 3 of 3