Health inspection·November 15, 2024

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the state and approved by CMS not less frequently than once every 3 months for 1 (Residents #1) of 18 residents reviewed for quarterly MDS assessments. Residents Affected - Few The facility failed to complete a quarterly MDS for Resident #1 with the ARD of 10/10/2024. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information for care plans. Findings included: Record review of Resident #1's face sheet, dated 11/15/2024, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (brain disorder that slowly destroys memory and think skills), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (heart muscle does not pump blood as well as it should), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), and hypertension (high blood pressure). Record review of Resident #1's MDS (assessment) tab in the electronic health record revealed her last completed quarterly MDS had an ARD of 07/11/2024, and the resident had an incomplete quarterly MDS with the ARD of 10/10/2024. The quarterly MDS, dated [DATE], was still in progress. Record review of Resident #1's quarterly MDS completed on 07/11/2024 section C (cognitive) revealed a BIMS score of 99 which indicated Resident #1 was unable to complete the assessment due to Alzheimer's disease (brain disorder that slowly destroys memory and think skills). In an interview on 11/14/2024 at 11:25 a.m., the DON acknowledged Resident #1's quarterly MDS with the ARD of 10/10/2024 was not completed. It was still in progress. Resident #1's quarterly MDS with the ARD of 10/10/2024 should have been completed on 10/10/2024. The facility lost their MDS nurse over one month ago, and had a consultant working MDS assessments at that time, but the MDS consultant was part time, so the MDS consultant was a little bit behind. In an interview on 11/14/2024 at 12:22 p.m., the MDS Consultant acknowledged Resident #1's quarterly MDS with the ARD of 10/10/2024 was not completed. It was still in progress and should have been completed on 10/10/2024. Because the MDS consultant was working as part time, she was a little bit behind. The MDS consultant stated she completed the assessment, but did not perform data entry yet. The MDS consultant said the incomplete quarterly MDS for Resident #1 could lead to the residents not Page 1 of 2 455618 455618 11/15/2024 Eden Home 631 Lakeview Blvd New Braunfels, TX 78130

F 0638 receiving correct care due to lack of current information for care plans. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, titled Resident Assessment, dated 05/05/2022, revealed 1. The current version of the RAI (MDS 3.0) will be utilized when conducting assessment. Completing CAAs, and care planning for each resident in accordance with the instructions and timeline dictated by the RAI Manual. Residents Affected - Few Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version must be no later than 14 days after the ARD. 455618 Page 2 of 2