Health inspection·January 29, 2025

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 the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to develop care plans 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 hemiplegia/hemiparesis (one side of the body is paralyzed or weak), difficulty in walking, and muscle weakness. Review of Resident 1's Change in Condition Evaluation, dated 8/22/24, indicated Resident 1 had an unwitnessed fall. Resident 1's MDS, dated [DATE], was reviewed. Section J1800 of the MDS was designated to indicate if the resident had any falls during the specified time frame. The individual who completed the MDS coded 0, which indicated the resident did not have any falls during the specified time frame. During an interview and concurrent record review with the MDS nurse (MDSN) on 1/29/25 at 10:37 a.m., the MDSN reviewed Resident 1's medical record and confirmed the resident had a fall on 8/22/24. The MDSN stated this fall should have been coded on the MDS dated [DATE], but confirmed it was not. The MDSN confirmed the individual who completed the MDS should have coded 1 in section J1800 to indicate that Resident 1 did have a fall during the specified time frame. Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions) indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame. 2. Review of Resident 1's Change in Condition Evaluation, dated 11/26/24, indicated Resident 1 had an open wound on her left arm due to pressure from a splint (a strip of rigid material used to immobilize a body part). Review of Resident 1's treatment administration record (TAR) indicated the resident received treatment for the above left arm pressure injury (injury to the skin and underlying tissue as a result of prolonged pressure) from 11/28/24 to 12/17/24. Resident 1's MDS, dated [DATE], was reviewed. Section M0210 of the MDS was designated to indicate if the resident had any unhealed pressure injuries. The individual who completed the MDS coded 0, Page 1 of 2 055739 055739 01/29/2025 Salinas Valley Post Acute 637 East Romie Lane Salinas, CA 93901

F 0641 which indicated Resident 1 did not have any unhealed pressure injuries. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review with the MDSN on 1/29/25 at 10:37 a.m., the MDSN reviewed Resident 1's medical record and confirmed the resident had a pressure injury that should have been coded on the MDS, dated [DATE], but was not. The MDSN confirmed the individual who completed the MDS should have coded 1 in section M0210 to indicated that Resident 1 did have an unhealed pressure injury. Residents Affected - Few The 2023 RAI Manual indicated for section M0210, Code 1, yes if the resident had any pressure injuries during the 7-day look back period. 055739 Page 2 of 2