Health inspection·November 14, 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, and facility policy review, the facility failed to ensure the preadmission screening and resident review (PASRR) was accurately completed for 1 (Resident #44) of 3 sampled residents reviewed for PASRR requirements. Specifically, Resident #44 had a serious mental illness (SMI) that was not captured in their Level I PASRR screening. Residents Affected - Few Findings included: A facility policy titled, PASRR Completion Policy, reviewed 12/2023, specified, The Center will a [sic] make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. The policy specified, 1. Center Administrator will designate the medical records to make sure that the [PASRR]and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which might constitute an SMI or ID [intellectual disability], the PASRR must be completed prior to admission. An admission Record revealed the facility admitted Resident #44 on 08/02/2024. According to the admission Record, the resident had a medical history that that included diagnoses of bipolar disorder (onset 08/02/2024) and anxiety disorder (onset 08/02/2024). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #44 had active diagnoses to include anxiety disorder and of manic depression (bipolar disease). Resident #44's care plan included a focus area initiated 08/05/2024, that indicated that the resident had a mood problem related to bipolar disorder and anxiety disorder. Interventions directed staff to refer the resident for behavioral health consultations as needed. Resident #44's physician orders revealed an order dated 08/04/2024, for quetiapine fumarate (an antipsychotic) oral tablet 24 milligrams, one tablet by mouth at bedtime for bipolar manifested by mood swings. Resident #44's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 08/02/2024, indicated that the resident had no diagnosed SMIs and did not have a suspected mental illness. During an interview on 11/13/2024 at 3:35 PM, the Social Services Director stated that the hospital completed the resident's Level I PASRR screening. She stated that she was not sure what the process was for the facility staff to review Level I PASRR screenings for accuracy or who was responsible for reviewing them. (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 7 Event ID: 555773 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 555773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indian Canyon Post Acute 57333 Joshua LN Yucca Valley, CA 92284 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)