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. Page 1 of 3 555200 555200 01/23/2024 Almond View Care Center 1224 E Street Williams, CA 95987

F 0644 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/23/2024 at 10:59 AM, the Administrator stated she did not think that a new mental illness diagnosis would require a new PASSAR to be completed. During an interview on 01/23/2024 at 11:17 AM, the Director of Nursing stated she did not do PASSARs, but she expected the policy to be followed. Residents Affected - Few 555200 Page 2 of 3 555200 01/23/2024 Almond View Care Center 1224 E Street Williams, CA 95987

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) level I screening for 1 (Resident #77) of 4 sampled residents reviewed for PASARR. Residents Affected - Few 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, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A review of Resident #77's admission Record revealed the facility admitted the resident on 12/09/2023, with diagnoses that included bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #77's Preadmission Screening and Resident Review Level I Screening, dated12/08/2023, revealed the resident did not have a serious diagnosed mental disorder such as depression disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, ad/or mood disturbance. A review of Resident #77's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/13/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder, depression, and bipolar disorder. A review of Resident #77's Order Summary Report, with active orders as of 01/23/2024, revealed an order dated 12/30/2023, for olanzapine (an antipsychotic medication) oral tablet 10 milligram (mg), give one tablet by mouth at bedtime for bipolar disorder and nortriptyline oral capsule 25 mg, give one capsule by mouth at bedtime for depression. During an interview on 01/23/2024 at 9:50 AM, the MDS Director indicated she was responsible for completing the PASARRs. When she would get the initial packet from the hospital, she would look through it and see if there were any mental diagnoses for the resident and add them to the Level I. Sometimes The MDS Director confirmed Resident #77's PASARR level I screening was inaccurate. Per the MDS Director, a level II examination should have been done for Resident #77. During an interview on 01/23/2024 at 11:00 AM, the Administrator stated Resident #77's mental illness diagnoses should have been included on the resident's PASARR level I screening. During an interview on 01/23/2024 at 11:17 AM, the Director of Nursing (DON) stated she did not do anything specific with the PASARRs, but indicated the PASARR was important to see what other services may be available for the resident. The DON stated her expectation was during the admission process, staff would make sure the documentation was correct. 555200 Page 3 of 3