Health inspection·May 16, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected preadmission screening and resident review (PASRR) information for 3 (Residents #2, #26, and #61) of 6 residents reviewed for PASRR requirements. Residents Affected - Some Findings included: A facility policy titled, Minimum Data Set (MDS) - Resident Assessment Instrument (RAI), dated 11/2017, revealed, 1. The facility shall complete a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by the Center of Medicaid and Medicare [NAME] (CMS), regardless of payer source, in facilities certified by the Medicare/Medicaid programs following the timeframes and instructions specified in the current CMS RAI Manual. The policy revealed, -Each responsible IDT [interdisciplinary team] staff who completes portion(s) of the MDS shall sign and certify the accuracy of the portion(s) of the MDS which he/she completed. The Centers for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.18.11, dated 10/2023, section A1500: Preadmission Screening and Resident Review (PASRR), revealed the Steps for Assessment included, 2. Review the Level I PASRR form to determine whether a Level II PASRR was required. 3. Review the PASRR report provided by the State if Level II screening was required. The manual 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 n admission Record indicated the facility admitted Resident #2 on 11/08/2023. According to the admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia, unspecified dementia, and anxiety disorder. Resident #2's Level II PASRR determination letter, dated 11/10/2023, revealed a Level I screening was conducted at the facility, followed by a Level II evaluation on 11/07/2023. The letter revealed the results of the Level II evaluation were provided in the PASRR Determination Report attached to the letter . Resident #2's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 11/10/2023, indicated Resident #2 required nursing facility services due to a medical and/or mental health condition and specialized services were recommended. Page 1 of 4 555514 555514 05/16/2024 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An admission MDS, with an Assessment Reference Date of (ARD) 11/15/2023, revealed the assessment was coded to reflect Resident #2 was not considered by the state Level II PASRR process to have a serious mental illness. Subsequently, the question about Level II PASRR conditions (A1510) was not answered. During an interview on 05/16/2024 at 1:18 PM, the Director of Nursing (DON) stated the MDS should accurately reflect the Level II PASRR status at the time of the assessment. She also stated that Resident #2's MDS was inaccurately coded regarding PASRR information. An admission Record indicated the facility admitted Resident #26 on 09/26/2023 and readmitted the resident on 01/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder bipolar type, major depressive disorder, and generalized anxiety disorder. Resident #26's Level II PASRR determination letter, dated 01/29/2024, revealed a Level I screening was conducted at the facility, followed by a Level II evaluation on 01/27/2024. The letter revealed the results of the Level II evaluation were provided in the PASRR Determination Report attached to the letter. Resident #26's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 01/29/2024, indicated Resident #26 required nursing facility services due to a medical and/or mental health condition and specialized services were recommended. A significant change in status MDS, with an ARD 03/25/2024, revealed the assessment was coded to reflect Resident #26 was not considered by the state Level II PASRR process to have serious mental illness. Subsequently, the question about Level II PASRR conditions was not answered. During an interview on 05/16/2024 at 1:14 PM, the DON stated the MDS should accurately reflect the Level II PASRR status at the time of the assessment. She also confirmed that Resident #26's MDS was inaccurately coded regarding PASRR information. An admission Record indicated the facility admitted Resident #61 on 11/13/2023. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, major depressive disorder, and psychosis. Resident #61's Level II PASRR determination letter, dated 11/10/2023, revealed a Level I screening was conducted at the facility, followed by a Level II evaluation on 11/09/2023. The letter revealed the results of the Level II evaluation were provided in the PASRR Determination Report attached to the letter. Resident #61's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 11/10/2023, indicated Resident #61 required nursing facility services due to a medical and/or mental health condition and specialized services were recommended. An admission MDS, with an ARD of 11/20/2023, revealed the assessment was coded to reflect Resident #61 was not currently considered by the state Level II PASRR process to have a serious mental illness. Subsequently, the question about Level II PASRR conditions was not answered. During an interview on 05/16/2024 at 1:11 PM, the DON stated Resident #61's MDS was not accurately 555514 Page 2 of 4 555514 05/16/2024 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some coded regarding the resident's PASRR information. She also stated she expected every section of the MDS to accurately reflect the status of the resident at the time of the assessment. During an interview on 05/15/2024 at 2:30 PM, after reviewing the MDS assessments, MDS Nurse #2 stated Resident #2, #26 and #61's MDS assessments were not accurately coded for their PASRR information. He stated the residents' Level II determination letters and recommendations were completed prior to the residents' MDS assessments, and he should have reviewed them and coded that the residents were considered by the state to have a serious mental illness. MDS Nurse #2 stated when coding the PASRR section of the MDS, he looked at the resident's paper chart and their electronic health record to see what was documented for PASRRs. MDS Nurse #2 stated if he did not see a level II in the records, he coded that the resident was not considered by the state as having a serious mental illness. MDS Nurse #2 stated he should have asked to see the residents' Level II determinations when he saw they had positive Level I PASRRs. During an interview on 05/16/2024 at 2:25 PM, the Administrator stated he expected MDS assessments to accurately reflect the status of a resident. He also stated that it was MDS staff's responsibility to ensure that all areas of the MDS were accurately coded. 555514 Page 3 of 4 555514 05/16/2024 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

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, and facility policy review, the facility failed to ensure the accuracy of a Level I preadmission screening and resident review (PASRR) for 1 (Resident #51) of 6 sampled residents reviewed for PASRR requirements. Specifically, Resident #59 had a diagnosis of schizoaffective disorder and major depressive disorder; however, the resident's Level I PASRR screening indicated the resident did not have a mental disorder. Residents Affected - Few Findings included: A facility policy titled, admission Criteria, revised in 03/2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) [also referred to as PASRR] process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. An admission Record revealed the facility admitted Resident #51 on 03/11/2024 and readmitted the resident on 03/27/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, schizoaffective disorder bipolar type, and major depressive disorder, all with an onset date of 03/27/2024. An admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #51 had active diagnoses that included non-Alzheimer's dementia, depression, and schizophrenia and had taken an antipsychotic medication during the seven-day assessment look-back period. Resident #51's care plan included a Problem area, initiated on 04/04/2024, that indicated the resident was admitted with an antipsychotic medication due to diagnosis of schizoaffective disorder. Resident #51's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 03/27/2024, revealed No was marked for Section III Serious Mental Illness which indicated the resident did not have a serious mental disorder such as depressive disorder or schizoaffective/schizophrenia disorder. During a telephone interview on 05/16/2024 at 4:44 PM, Registered Nurse (RN) #1, Resident #51's admitting nurse, revealed that it was an oversight on her part and indicated she did not catch that the PASRR indicated the resident did not have a mental disorder. RN #1 confirmed that Resident #51 had a mental disorder diagnosis. During an interview on 05/16/2024 at 10:42 AM, the Director of Nursing (DON) revealed it was the responsibility of the admitting nurse to ensure that a PASRR was accurately coded. The DON indicated that if a PASRR was not accurate, she expected the admitting nurse to create a new PASRR. During an interview on 05/16/2024 at 1:33 PM, the Administrator stated his expectation was for the admitting nurse to review PASRR screenings for accuracy when the hospital sent them to the facility. The Administrator indicated that it was also his expectation that the admitting nurse notify the DON or Administrator if the PASRR was not accurate so that the appropriate corrections could be made. 555514 Page 4 of 4