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. (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: 555514 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 555514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786 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)