Health inspection·January 23, 2024

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 interviews, record reviews, and facility policy review, the facility failed to refer 2 (Resident #40 and Resident #55) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR) when the resident received a new mental illness diagnosis. Findings included: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, implemented on 07/23/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder [MD], intellectual disability [ID], or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. Review of Resident #40's admission Record revealed the facility admitted the resident on 02/02/2022. Per the admission Record, on 02/17/2022, the resident received a diagnosis of post-traumatic stress disorder, on 03/18/2022, a diagnosis of anxiety disorder, and on 09/26/2023, a diagnosis of depression. Review of Resident #40's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder and post-traumatic stress disorder. Review of Resident #55's admission Record revealed the facility admitted the resident on 06/24/2019. Pe the admission Record, the resident received a diagnosis of generalized anxiety disorder on 04/07/2022. Review of Resident #55's quarterly MDS, with an ARD of 06/17/2022, revealed Resident #55 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder, depression, and psychotic disorder. During an interview on 01/23/2024 at 9:50 AM, the MDS Director, stated a new PASARR screen was not completed for Resident #40 or Resident #55 when the residents received new mental health diagnoses. The MDS Director stated she thought a new PASSAR was only required if the resident had behaviors or symptoms after receiving a new mental health diagnosis. (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: 555200 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 555200 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Almond View Care Center 1224 E Street Williams, CA 95987 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)