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 (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 3 Event ID: 056136 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 056136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Mesa Care Center 867 E. 11th St Upland, CA 91786 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)