Health inspection·January 22, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview and record review, the facility failed to complete Minimum Data Set (MDS - a resident clinical assessment tool) assessments within the required time frame for two of 51 residents (Resident 1 and 2). This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: Review of Resident 1's MDS schedule, indicated there was no annual MDS (a comprehensive MDS assessment followed by the development and/or review of the comprehensive care plan) or quarterly MDS (non-comprehensive MDS) completed between 11/17/22 and 7/25/23. Review of Resident 2's MDS schedule, indicated there was no annual MDS or quarterly MDS completed between 11/11/22 and 8/15/23. During a concurrent interview and record review on 1/22/24 at 1:12 p.m. with MDS Coordinator (MDSC), she confirmed Resident 1's annual MDS due in February 2023 was not completed, and a quarterly MDS due in May 2023 was not completed. MDSC also confirmed for Resident 2, an annual MDS due in February 2023 and a quarterly MDS due in May 2023 were not completed. She stated MDS assessments should be done every three months, and due to incompletion of MDS assessments, there was no documented evidence that Resident 1 and 2's care plans were reviewed. During a concurrent interview and record review on 1/22/24 at 2 p.m. with Social Services Designee (SSD), she confirmed there was no documented evidence that Resident 1 and 2's care plans were reviewed in February 2023 and May 2023. She stated she would schedule care plan meeting with the resident's family based on MDS schedule, each resident's care plans were reviewed at least every three months, and the process involved the IDT (interdisciplinary team, a group of health care professionals with various areas of expertise who work together toward the goals of their residents). During an interview on 1/22/24 at 2:20 p.m. with the Director of Nursing (DON), she stated MDS was supposed to be done quarterly, and she confirmed there was no evidence that Resident 1 and 2's care plans were reviewed quarterly. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The ARD (assessment reference date) must be set within 366 days after the ARD of the previous comprehensive assessment AND within 92 days since the ARD of the previous Page 1 of 5 555538 555538 01/22/2024 Eden Valley Care Center 612 Main Street Soledad, CA 93960

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Quarterly. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered, revised March 2022, the P&P indicated, 12. The interdisciplinary team reviews and updates the care plan: d. at least quarterly, in conjunction with the required quarterly MDS assessment. 555538 Page 2 of 5 555538 01/22/2024 Eden Valley Care Center 612 Main Street Soledad, CA 93960

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 Based on interview and record review, the facility failed to complete Minimum Data Set (MDS - a resident clinical assessment tool) assessments within the required time frame for two of 51 residents (Resident 1 and 2). This deficient practice had the potential to negatively affect the provision of necessary care and services. Residents Affected - Few Findings: Review of Resident 1's MDS schedule, indicated there was no annual MDS (a comprehensive MDS assessment followed by the development and/or review of the comprehensive care plan) or quarterly MDS (non-comprehensive MDS) completed between 11/17/22 and 7/25/23. Review of Resident 2's MDS schedule, indicated there was no annual MDS or quarterly MDS completed between 11/11/22 and 8/15/23. During a concurrent interview and record review on 1/22/24 at 1:12 p.m. with MDS Coordinator (MDSC), she confirmed Resident 1's annual MDS due in February 2023 was not completed, and a quarterly MDS due in May 2023 was not completed. MDSC also confirmed for Resident 2, an annual MDS due in February 2023 and a quarterly MDS due in May 2023 were not completed. She stated MDS assessments should be done every three months, and due to incompletion of MDS assessments, there was no documented evidence that Resident 1 and 2's care plans were reviewed. During a concurrent interview and record review on 1/22/24 at 2 p.m. with Social Services Designee (SSD), she confirmed there was no documented evidence that Resident 1 and 2's care plans were reviewed in February 2023 and May 2023. She stated she would schedule care plan meeting with the resident's family based on MDS schedule, each resident ' s care plans were reviewed at least every three months, and the process involved the IDT (interdisciplinary team, a group of health care professionals with various areas of expertise who work together toward the goals of their residents). During an interview on 1/22/24 at 2:20 p.m. with the Director of Nursing (DON), she stated MDS was supposed to be done quarterly, and she confirmed there was no evidence that Resident 1 and 2's care plans were reviewed quarterly. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The ARD (assessment reference date) must be set within 366 days after the ARD of the previous comprehensive assessment AND within 92 days since the ARD of the previous Quarterly. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered, revised March 2022, the P&P indicated, 12. The interdisciplinary team reviews and updates the care plan: d. at least quarterly, in conjunction with the required quarterly MDS assessment. 555538 Page 3 of 5 555538 01/22/2024 Eden Valley Care Center 612 Main Street Soledad, CA 93960

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to develop comprehensive care plans and update these care plans for two of 51 Residents (Resident 1 and 2) in accordance with the Minimum Data Set (MDS - a resident clinical assessment tool) assessments required time frame. This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: Review of Resident 1's MDS schedule, indicated there was no annual MDS (a comprehensive MDS assessment followed by the development and/or review of the comprehensive care plan) or quarterly MDS (non-comprehensive MDS) completed between 11/17/22 and 7/25/23. Review of Resident 2's MDS schedule, indicated there was no annual MDS or quarterly MDS completed between 11/11/22 and 8/15/23. During a concurrent interview and record review on 1/22/24 at 1:12 p.m. with MDS Coordinator (MDSC), she confirmed Resident 1's annual MDS due in February 2023 was not completed, also a quarterly MDS due in May 2023 was not completed. MDSC also confirmed for Resident 2, an annual MDS due in February 2023 and a quarterly MDS due in May 2023 were not completed. She stated MDS assessments should be done every three months, and due to incompletion of MDS assessments, there was no documented evidence that Resident 1 and 2's care plans were reviewed. During a concurrent interview and record review on 1/22/24 at 2 p.m. with Social Services Designee (SSD), she confirmed there was no documented evidence that Resident 1 and 2's care plans were reviewed in February 2023 and May 2023. She stated she would schedule care plan meeting with the resident's family based on MDS schedule, each resident's care plans were reviewed at least every three months, and the process involved the IDT (interdisciplinary team, a group of health care professionals with various areas of expertise who work together toward the goals of their residents). During an interview on 1/22/24 at 2:20 p.m. with the Director of Nursing (DON), she stated MDS was supposed to be done quarterly, and she confirmed there was no evidence that Resident 1 and 2's care plans were reviewed quarterly. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated the following: The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days). The ARD (assessment reference date) must be set within 366 days after the ARD of the previous comprehensive assessment AND within 92 days since the ARD of the previous Quarterly. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident ' s status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. During a review of the facility's policy and procedure (P&P) titled Care Plan, Comprehensive Person-Centered, revised March 2022, the P&P indicated, 12. The interdisciplinary team reviews and updates 555538 Page 4 of 5 555538 01/22/2024 Eden Valley Care Center 612 Main Street Soledad, CA 93960

F 0657 the care plan: d. at least quarterly, in conjunction with the required quarterly MDS assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555538 Page 5 of 5