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 Page 1 of 3 555870 555870 07/26/2024 Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was responsible for submitting another PASRR if the one completed by the hospital was not accurate and did not reflect all diagnoses. During an interview on 07/26/2024 at 10:00 AM, the Director of Nursing (DON) stated facility staff pulled PASRRs from the system but indicated they should be reviewing them for accuracy and updating them if needed. During an interview on 07/26/2024 at 10:55 AM, the Administrator stated she expected PASRRs to be complete and accurate. 555870 Page 2 of 3 555870 07/26/2024 Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility policy review, the facility failed to ensure expired medications and/or biologicals were removed from 1 (Station 1) of 2 medication storage rooms and 1 of 1 central supply closet. Findings included: A facility policy titled, Storage of Medications, revised in 11/2020, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy specified, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. An observation on 07/24/2024 at 12:07 PM of the medication storage room located on Station 1 revealed a Nozin Nasal Sanitizer with an expiration date of 03/2024. During an interview on 07/25/2024 at 12:09 PM, Registered Nurse (RN) #3 stated the Nozin Nasal Sanitizer was not supposed to be in the medication storage room, because it was expired. An observation on 07/24/2024 at 12:16 PM of the central supply closet revealed two boxes of Tucks (medicated pads) with an expiration date of 03/2024. During an interview on 07/25/2024 at 12:13 PM, the Director of Nursing (DON) said a routine check of stored medications should be conducted weekly. The DON said when expired medications were found, they should be discarded. The DON confirmed the Nozin Nasal Sanitizer and two boxes of Tucks should have been discarded prior to the survey. During an interview on 07/26/2024 at 10:57 AM, the Administrator said there should be no expired medications in any medication storage areas. The Administrator stated expired medications should be removed and disposed of. 555870 Page 3 of 3