Health inspection·December 27, 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 and record review, the facility failed to accurately code the required resident assessment for 1 resident reviewed for accuracy of assessments. Residents Affected - Few This failure had the potential for not identifing Resident 1's needs. Findings: An unanounced visit was made to the facility on [DATE] in response to a report of a fall. Record review was initiatied on 12/10/24. Resident 1 was admitted to the facility on [DATE] with health conditions which ncluded need for assistance with personal care and unspecified hearing loss according to the admission Record. On 12/10/24 at 11:38 A.M., Licensed Nurse (LN) 3 was interviewed. LN 3 stated Resident 1 was deaf, and preferred to have staff write questions to her, and she would answer verbally. On 12/10/24 at 11:40 A.M., Resident 1 was interviewed. The questions were written and answered verbally by Resident 1. Resident 1 laughed when asked if one ear was better than another. Resident 1 stated both ears are crap. On 12/10/24 at 2:10 P.M., an interview and joint review of Resident 1's clinical records was conducted with the Case manager (CM). The History & Physical note dated, 3/20/24 indicated, Resident 1 was deaf and verbally responds to written communication, and does not use sign language. Resident 1 is alert and oriented, (thinking ability and general memory is intact) and able to make her own decisions. A hospital Social Worker note dated, 2/28/24 indicated, Resident 1 was deaf, and an interview was conducted with the social worker writing, and Resident 1 responding verbally. The facility Nursing admission assessment dated , 3/18/24 indicated, Resident 1's ability to hear was Highly Impaired (Absence of useful hearing); and was alert and oriented (thinking and memory intact). The MDS (minimum data set- a required facility assessment for all residents) dated, 3/24/24 (admission), 6/18/24 (quarterly) and 9/12/24 (quarterly) assessments indicated, Resident 1's hearing was Adequate -no difficulty in normal conversation, social interaction, listening to TV. Page 1 of 2 055182 055182 12/27/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0641 Level of Harm - Minimal harm or potential for actual harm The CM stated the expectation was, all MDS assessments were to be completed in person. After reviewing the records, the CM stated the Social Worker (SW 1) who completed the 9/12/24 assessment for Resident 1's hearing made a mistake. The CM also stated she did not know how this would have been done. SW 1 was not available for interview. Residents Affected - Few On 12/10/24 at 2:15 P.M., an interview and review of the same records was conducted with the MDS Coordinator Nurse (LN 1). LN 1 stated all interviews and assessments were completed face to face with the residents. LN 1 verified she had signed the MDS hearing assessments dated 3/24/24 and 6/18/24 for Resident 1. LN 1 stated she did not remember why she coded the assessments as Adequate for Resident 1. 055182 Page 2 of 2