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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 555538 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Valley Care Center 612 Main Street Soledad, CA 93960 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)