Health inspection·July 17, 2024

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, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurately completed for 1 (Resident #30) of 2 sampled residents reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #30's Level I PASARR Screening reflected the presence of a serious diagnosed mental disorder. Residents Affected - Few Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, revised 12/18/2023, specified, This facility coordinates assessments with the preadmission screening and resident review (PASARR) 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. The California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine if the individual may have a serious mental illness and benefit from specialized services. Question 10. Diagnosed Mental Illness *Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? *If yes, there will be a text box question [to] provide the type of mental illness. An admission Record revealed the facility admitted Resident #30 on 06/11/2024. According to the admission Record, the resident's admitting diagnoses included major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/2024, revealed Resident #30 had severely impaired cognitive skills for daily decision making and had short- and long-term memory problems per a Staff Assessment for Mental Status (SAMS). The MDS indicated Resident #30 had an active diagnosis of depression. Resident #30's undated Care Plan Detail included a focus area that indicated Resident #30 had depression. Resident #30's History and Physical Exam, dated 06/13/2024, indicated Resident #30 had a diagnosis of major depressive disorder. Resident #30's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated (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 2 Event ID: 555266 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 555266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Mar Nursing Center 1720 West Orange Avenue 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)