Health inspection·July 26, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 (Resident 41 and Resident #45) of 13 sampled residents. Specifically, the facility failed to code Resident #41 received hospice care and Resident #45 received an antidepressant medication. Residents Affected - Few Findings included: An undated facility policy titled, Certifying Accuracy of the Resident Assessment, indicated, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 1. An admission Record indicated the facility admitted Resident #41 on 12/10/2021. According to the admission Record, the resident had a medical history that included a diagnosis of senile degeneration of the brain. Resident #41's Order Summary Report, for active orders as of 07/01/2024, indicated an order dated 05/23/2024, to admit the resident to hospice services. A significant change in status assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #41 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS did not indicate the resident received hospice care. Resident #41's care plan, included a focus area initiated 05/24/2024, that indicated the resident was on hospice care for the diagnosis of senile degeneration of the brain. During an interview on 07/26/2024 at 8:28 AM, the MDS Coordinator stated the MDS reflected a resident's baseline status, their function and mobility to track if the resident improved and/or declined. The MDS Coordinator stated the information came from the nurse's documentation, certified nursing assistant charting for activities of daily living function, physician notes during the look-back period, physician orders and medications including psychotropic medications. The MDS Coordinator stated the significant change in status assessment MDS was completed for Resident #41 because the resident was not at their baseline and was placed on hospice services. The MDS Coordinator stated she coded that the resident's life expectancy was less than six months; however, she confirmed that hospice was not coded, but it should have been. Page 1 of 7 555025 555025 07/26/2024 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/26/2024 at 8:54 AM, the Director of Nursing (DON) stated the MDS was a resident assessment that was developed for the improvement of residents and should be coded correctly to accurately reflect the resident. The DON stated the information for the MDS came from interviews, observations, and chart review. The DON stated Resident #41 was placed on hospice and when the significant change in status assessment was completed, hospice care should have been coded. The DON stated it was her expectation that the MDS be coded correctly. During an interview on 07/26/2024 at 9:04 AM, the Administrator stated he did not have anything to do with the MDS process, but expected the MDS to be coded correctly. 2. An admission Record revealed the facility admitted Resident #45 on 11/03/2022. According to the admission Record the resident had a medical history that included a diagnosis of dementia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #45 did not take an antidepressant medication. Resident #45's Order Summary Report, with active orders as of 05/04/2024, revealed an order dated 04/02/2024, for escitalopram (an antidepressant medication) 10 milligrams, give one tablet by mouth one time a day for episode of self-isolation manifested by reduced social interaction. Resident #45's Medication Administration Record, for the timeframe 05/01/2024 to 05/31/2024, revealed staff documented they administered escitalopram to Resident #45 at 9:00 AM on 05/01/2024 to 05/03/2024 and 05/08/2024 to 05/31/2024. During an interview on 07/26/2024 at 8:28 AM, the MDS Coordinator stated the antidepressant medication for Resident #45 should have been coded on the resident's MDS. During an interview on 07/26/2024 at 8:54 AM, the Director of Nursing stated it was her expectation that the MDS be coded correctly. During an interview on 07/26/2024 at 9:04 AM, the Administrator stated he did not have anything to do with the MDS process, but expected the MDS to be coded correctly. 555025 Page 2 of 7 555025 07/26/2024 University Post Acute 2278 Nice Ave Mentone, CA 92359

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, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed when a resident received a new mental diagnosis for 1 (Resident #18) of 3 sampled residents reviewed for PASARRs. Findings included: A typed document from the California Department of Health Care Services, dated 09/09/2023, specified Per Title 42 of the Code of Federal Regulations sections 483.100 through 483.138, individuals identified with a SMI [serious mental illness] and/or ID/DD/RD [intellectual disability/developmentally disability/related condition] must be screened and evaluated to determine whether SNF [skilled nursing facility] level of care and specialized services in the least restrictive setting that best meets their needs are required. An admission Record revealed the facility admitted Resident #18 on 03/18/2022. According to the admission Record, on 04/06/2022, the resident received diagnoses of anxiety disorder, depression, and schizoaffective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #18 had active diagnoses to include anxiety disorder, depression, and schizophrenia. Resident #18's care plan included a focus area updated 02/08/2024, that indicated the resident took psychotropic medications due to schizoaffective disorder manifested by auditory hallucinations secondary to hearing non-existent voices. Resident #18's care plan included a focus area updated 02/08/2024, that indicated the resident used valproic acid for mood disorder manifested by mood swings which caused angry outbursts. Resident #18's medical record revealed no evidence to indicate a PASARR evaluation was completed after the resident was diagnosed with anxiety disorder, depression, and schizophrenia. During an interview on 07/26/2024 at 8:50 AM, the Assistant Director of Nursing stated she submitted Resident #18's Level I PASARR; however, the resident received new diagnoses after they were assessed by physician and she did not know a new one PASARR needed to be completed. During an interview on 07/26/2024 at 8:55 AM, the Director of Nursing stated Resident #18's PASARR should have been resubmitted with the resident's new serious mental illness diagnoses. 555025 Page 3 of 7 555025 07/26/2024 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for 1 (Resident #6) of 3 sampled residents reviewed for PASARRs. Residents Affected - Few Findings included: A typed document from the California Department of Health Care Services, dated 09/09/2023, specified Per Title 42 of the Code of Federal Regulations sections 483.100 through 483.138, individuals identified with a SMI [serious mental illness] and/or ID/DD/RD [intellectual disability/developmentally disability/related condition] must be screened and evaluated to determine whether SNF [skilled nursing facility] level of care and specialized services in the least restrictive setting that best meets their needs are required. An admission Record revealed the facility admitted Resident #6 on 10/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder, schizoaffective disorder, unspecified psychosis, and suicidal ideation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #6 had active diagnoses to include anxiety disorder, psychotic disorder, and schizophrenia. Resident #6's care plan included a focus area initiated 10/18/2023, that revealed Resident #6 was at risk for being resistive to care related to anxiety, dementia, schizoaffective disorder, psychosis and suicidal ideation. A care plan, initiated 10/19/2023, revealed Resident #6 used antipsychotic medication for schizoaffective disorder manifested by delusions that led to aggressive behaviors. A care plan, updated 02/08/2024, revealed Resident #6 used antidepressant medication for depression manifested by an inability to sleep and diagnoses of depression, anxiety disorder, schizoaffective disorder and psychosis. Resident #6's Preadmission Screening and Resident Review Level I Screening, dated 10/18/2023, revealed a negative Level I outcome due to a 30-day Exempted Hospital Discharge. Resident #6's medical record revealed no evidence to indicate a PASARR evaluation was completed after the resident remained in the facility 30 days after admission. During an interview on 07/26/2024 at 8:50 AM, the Assistant Director of Nursing (ADON) stated she was the one that reviewed the PASARRs. The ADON stated Resident #6's PASARR was missed because she was not familiar with the 30-day exemption/resubmission. During an interview on 07/26/2024 at 8:55 AM, the Director of Nursing stated Resident #6's PASARR should have been resubmitted when the 30 day period was completed. 555025 Page 4 of 7 555025 07/26/2024 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure residents room' measured at least 80 square (sq) feet (ft) per resident in 19 (Rooms 1 - 8 and 11-21) 21 resident rooms in the facility. Findings included: The Client Accommodations Analysis, completed by the Administrator and dated 07/25/2024 revealed: In room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, 555025 Page 5 of 7 555025 07/26/2024 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0912 which yielded 73.2 sq ft for each resident. Level of Harm - Potential for minimal harm - Residents Affected - Many In room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 151.28 sq ft and two beds occupied the room, which yielded 75.64 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. 555025 Page 6 of 7 555025 07/26/2024 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many In room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident. In room [ROOM NUMBER], the total floor area measured 139.7 sq ft and two beds occupied the room, which yielded 69.85 sq ft for each resident. In an interview on 07/26/2024 at 7:55 AM, with the Director of Maintenance confirmed the room measurements were accurate, and added that most resident rooms did not meet the federal room regulation size. In an interview on 07/26/2024 at 8:55 AM, the Administrator stated there had been no issues with care in relation to the resident room size and the facility did not have a policy regarding room size. 555025 Page 7 of 7