Health inspection·August 22, 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 complete a Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1), when Resident 1's MDS weight and continence were inaccurately documented. Failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs. Residents Affected - Few Findings: 1. Review of Resident 1's medical record indicated the resident was admitted on [DATE] and had diagnoses including femur fracture (a break in the thigh bone), sepsis (an extreme bodily response to an infection), obesity (a disorder that involves having excessive body fat), and kidney disease. Review of Resident 1's Weights and Vitals Summary indicated Resident 1 weighed 231.4 pounds (lbs, unit of weight measurement) on 7/17/24. The Weights and Vitals Summary further indicated Resident 1 weighed 220.8 lbs on 7/22/24. Resident 1's MDS, dated [DATE], was reviewed. Section K0200 was designated to document the resident's most recent weight. The individual who completed the MDS documented that Resident 1 weighed 231 lbs. During an interview and concurrent record review with the registered dietician (RD) on 8/22/24, at 12:40 p.m., the RD reviewed Resident 1's medical record and confirmed the resident's most recent weight was 220.8 lbs. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 8/22/24, at 2:06 p.m., the MDSC confirmed Resident 1's MDS, dated [DATE], was not accurate. The MDSC confirmed the individual who completed the MDS should have documented Resident 1's most recent weight in section K0200. Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2023, indicated for section

K0200, Base weight on most recent measure in last 30 days. 2. Resident 1's MDS, dated [DATE], was reviewed. Section H of the MDS was designated to indicate whether the resident was continent (able to control urination and defecation) or incontinent (unable to control urination and defecation). The individual who completed the MDS coded 0 to indicate Resident 1 was Always continent with both urination and defecation. Page 1 of 2 055739 055739 08/22/2024 Salinas Valley Post Acute 637 East Romie Lane Salinas, CA 93901

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's Documentation Survey Report indicated from 7/21/24 to 7/27/24, Resident 1 was incontinent with urination 15 times and was continent six times. The Documentation Survey Report further indicated for the same time frame, Resident 1 was incontinent with defecation nine times and was continent zero times. During an interview and concurrent record review with the MDSC on 8/22/24, at 2:06 p.m., the MDSC reviewed Resident 1's medical record and confirmed the resident was incontinent with both urination and defecation from 7/21/24 to 7/27/24. The MDSC confirmed Resident 1's MDS, dated [DATE], was not accurate. The MDSC stated the individual who completed the MDS should have indicated Resident 1 was frequently incontinent with urination and always incontinent with defecation. Review of the RAI Manual, dated 10/2023, indicated for section H, Code 2, frequently incontinent: if during the 7-day look-back period, resident was incontinent of urine during seven or more episodes but had at least one continent void [urination]. The RAI Manual further indicated, Code 3, always incontinent: if during the 7-day look-back period, the resident was incontinent of bowel for all bowel movements [defecation] and had no continent bowel movements. 055739 Page 2 of 2