Health inspection·March 8, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, 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 the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #60) of 3 sampled residents reviewed for Preadmission Screening and Resident Review (PASSR) requirements. Specifically, the facility failed to ensure Resident #60's annual MDS, with an Assessment Reference Date (ARD) of 07/07/2023, reflected that the resident was considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Residents Affected - Few Findings included: A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, dated October 2023, Chapter 3: Overview to the Item-By-Item Guide to the MDS 3.0, A1500: Preadmission Screening an Resident Review (PASRR), revealed, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. A review of an admission Record revealed the facility most recently admitted Resident #60 on 04/06/2022 with diagnoses that included schizoaffective disorder, anxiety disorder, paranoid schizophrenia, bipolar disorder, bipolar two disorder, and mental disorder not otherwise classified. A review of Resident #60's Care Plan, revealed a Focus area, initiated on 04/06/2022 and revised on 06/09/2022, that indicated the resident had behavior manifestations related to diagnoses of schizophrenia, mood disorder, and insomnia. Further review of Resident #60's Care Plan revealed multiple Focus areas that indicated the resident was at risk for adverse effects from psychotropic medications with black box warnings, including Haldol (an anti-psychotic medication), risperidone (an atypical anti-psychotic medication), Caplyta (an atypical anti-psychotic medications), and buspirone (an anti-anxiety medication). A review of a Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 06/17/2022, revealed a Level II PASRR review was completed, and specialized services were recommended, which included services and supports to supplement nursing facility care to address the resident's mental health needs. A review of an annual MDS, with an ARD of 07/07/2023, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident had active diagnoses that included anxiety disorder, bipolar disorder, schizophrenia, and a mental disorder not otherwise specified. Section A1500, for whether the resident was (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 9 Event ID: 555035 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 555035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Anaheim Healthcare Center 3435 W Ball Road Anaheim, CA 92804 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)