Health inspection·July 26, 2024

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 Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of a diagnosed mental disorder for 1 (Resident #44) of 5 residents reviewed for PASRR requirements. Residents Affected - Few Findings included: An undated facility policy titled, Preadmission Screening and Resident Review revealed, Purpose: To ensure that all facility applicants are screened for mental illness and/or intellectual disability and to ensure coordination with the appropriate state agencies if indicated. The policy specified, II. The Facility, ensures that PASRR Level I is completed either by the transferring general acute care hospital (GACH), or by the Facility for all applicants, regardless of Payor source, prior to admission to determine if they have a serious mental illness (SMI) and/or intellectual disability, developmental disability or related condition(s) (ID/DD/RC). An admission Record revealed the facility admitted Resident #44 on 06/04/2024. According to the admission Record, the resident had a medical history that included a diagnosis of major depressive disorder, with an onset date of 06/04/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an active diagnosis of depression. Resident #44's care plan included a Focus area initiated on 06/05/2024, that indicated the resident exhibited negative mood/behaviors related to depression. A Focus area, initiated on 06/06/2024, indicated the resident received citalopram (an antidepressant medication) related to a diagnosis of mental illness, specifically depression. Resident #44's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/03/2024, revealed the resident's diagnosis of major depressive disorder was not reflected. The question related to whether the resident had 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 answered no, resulting in a negative screening; thus, a Level II evaluation was not required. During an interview on 07/25/2024 at 10:54 AM, Medical Records (MR) Staff #1 stated that she was responsible for reviewing PASRRs completed by the hospital to make sure they were correct. MR Staff #1 said if a resident had a mental illness, it had to be reflected on their PASRR. MR Staff #1 said (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 3 Event ID: 555870 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 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 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)