Health inspection·May 30, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and document review, the facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments for 2 (Resident #38 and Resident #51) of 2 sampled residents reviewed for resident assessment. Residents Affected - Few Findings included: 3.0 User's Manual, dated 10/2023, indicated, Discharge assessment refers to an assessment required on resident discharge from the facility. 1. An admission Record revealed the facility initially admitted Resident #38 on 12/13/2023. According to the admission Record, the resident had a medical history that included diagnoses of pleural effusion, atrial fibrillation, and peripheral vascular disease. An admission MDS, with an Assessment Reference Date (ARD) of 12/19/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Resident #38's Progress Notes, dated 02/20/2024 at 6:08 PM, revealed Resident #38 discharged from the facility. Review of Resident #38's medical record, revealed no evidence to indicate a discharge MDS was completed. 2. An admission Record revealed the facility initially admitted Resident #51 on 01/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of left radius fracture, type two diabetes mellitus, and morbid obesity. An admission MDS, with an Assessment Reference Date (ARD) of 01/21/2024, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Resident #51's Progress Notes, dated 02/17/2024 at 6:50 PM, revealed Resident #51 discharged from the facility. Review of Resident #51's medical record, revealed no evidence to indicate a discharge MDS was completed. Page 1 of 2 055800 055800 05/30/2024 Stonebrook Health and Rehabilitation 350 DE Soto Drive Los Gatos, CA 95032

F 0640 Level of Harm - Minimal harm or potential for actual harm During an interview on 05/30/2024 at 12:04 PM, the MDS Coordinator stated the facility's electronic medical record system generated a report which showed when a resident's MDS assessments were due. The MDS Coordinator stated when a resident discharged from the facility, the facility was required to complete and submit a discharge MDS within 14 days. The MDS Coordinator stated Resident #38 and Resident #51 should have had a completed and submitted discharge MDS assessment. Residents Affected - Few During an interview on 05/30/2024 at 12:10 PM, the Director of Nursing stated she expected the discharge MDS to be completed and submitted within the required 14 days. During an interview on 05/30/2024 at 12:53 PM, the Administrator stated he expected MDS assessments to be submitted timely and expected the nursing department to complete a resident's MDS assessment as required. 055800 Page 2 of 2