Health inspection·June 26, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment for 1 (Resident #13) of 3 residents reviewed for MDS discrepancies accurately reflected the resident was receiving an antiplatelet medication, instead of indicating the resident received an anticoagulant medication. Residents Affected - Few Findings included: CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, Chapter 3: MDS Items, N0415: High Risk Drug Classes: Use and Indication, revealed, Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day-look-back period (or since admission/entry or reentry if less than 7 days. The RAI User's Manual further indicated, Coding Instructions *Code all high-risk medications according to their pharmacological classification, not how they are being used. The manual specified N0415I1. Antiplatelet should be checked if medications, including clopidogrel, were taken by the resident at any time during the 7-day observation period. An admission Record revealed the facility admitted Resident #13 on 05/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure, peripheral vascular disease, and hypertension. Resident #13's Order Summary Report, listing active orders as of 06/26/2024, contained an order, started on 05/30/2024, for clopidogrel bisulfate (an antiplatelet medication), 75 milligrams (mg), one tablet by mouth one time a day for blood clot prevention. The Order Summary Report did not reflect any orders for medications classified as anticoagulants. Resident #13's care plan included a focus area, initiated 05/29/2024, that indicated the resident was at risk for abnormal bruising or bleeding related to antiplatelet medication use. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2024, revealed Resident #13 was coded under section N0415 as having received an anticoagulant medication, instead of an antiplatelet medication, during the seven-day look-back period. During an interview on 06/26/2024 at 12:43 PM, the MDS Director stated MDS assessments were coded according to what medications a resident was receiving. The MDS Director confirmed clopidogrel bisulfate was an antiplatelet medication and should be coded on the MDS as an antiplatelet medication. During an interview on 06/26/2024 at 1:14 PM, the Administrator stated she expected MDS assessments Page 1 of 2 056037 056037 06/26/2024 Pacific Hills Post Acute 370 Noble Court Morgan Hill, CA 95037

F 0641 to be accurately coded. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056037 Page 2 of 2