Health inspection·February 13, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) was accurately completed for 1 (Resident #105) of 3 sampled residents reviewed for PASARR requirements. Residents Affected - Few Findings included: A facility policy titled, admission Criteria, revised March 2023, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission and Resident Review (PASARR) process. a. The acute hospital performs a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. An admission Record indicated the facility admitted Resident #105 on 12/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder and generalized anxiety disorder. Resident #105's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had active diagnoses of anxiety disorder and bipolar disorder. Resident #105's Care Plan, revealed a focus area, initiated 12/12/2024, that indicated the resident was at risk for changes in behavior due to diagnoses of depression, anxiety, and bipolar disorder. Additionally, Resident #105's Care Plan revealed a focus area, initiated 12/12/2024, that indicated Resident #105 had the potential for side effects, complications, or adverse reactions related to ordered use of Seroquel (an antipsychotic medication) related to bipolar disorder. Resident #105's Level I PASARR, dated 12/12/2024, revealed Section III - Serious Mental Illness reflected that the resident did not 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, was not suspected to have a mental illness, and had not been prescribed psychotropic medications for a serious mental illness. (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 4 Event ID: 555446 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 555446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rossmoor Post Acute 1226 Rossmoor Parkway Walnut Creek, CA 94595 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)