Health inspection·June 10, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the accuracy of the Minimum Data Set (MDS, an assessment tool) for two (2) of six (6) sampled residents (Residents 1 and 2) when: Residents Affected - Few 1. For Resident 1, the number of Pressure Injury (PI, a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure, or pressure in combination with shear), Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence), was inaccurately coded as two (2) instead of one (1) on the MDS, section M. 2. For Resident 2, the number of PI, Stage 3 (full thickness tissue loss. Subcutaneous fat maybe visible but bone, tender or muscle is not exposed. Slough maybe present but does not obscure the depth of tissue loss) was inaccurately coded as four (4) instead of three (3) on MDS, section M. These deficient practices had the potential to negatively affect the care and services rendered to the residents. Findings: 1.Record review of the Face Sheet dated 6/10/25 indicated, Resident 1 was admitted to the facility on [DATE]. In an interview on 6/10/25, at 10:14 AM, with the Wound Care Nurse (WCN 1), WCN 1 stated, Resident 1 has PI in the coccyx (tailbone), it's resolving. Record review of the History and Physical (H&P) dated 4/29/25 indicated, the diagnoses that included subdural hematoma (a buildup of blood on the surface of the brain), vascular dementia (changes to memory, thinking, and behavior caused by reduced blood flow to the brain), Parkinson's disease (movement disorder). In a concurrent record review and interview on 6/10/25, at 11:20 AM, with the MDS Coordinator (MDS-C1), the admission MDS dated [DATE], was reviewed. The MDS section M0300, Current number of Unhealed Pressure Ulcers/injuries at Each stage, A. Stage 1, was reviewed. The MDS section M0300 section A. Stage 1 indicated, 1. Number of Stage 1 PI was marked 2 (two) in the box next to it. The MDS-C1 stated, the resident has one (1) Stage 1 pressure injury in the coccyx, but it was documented two (2). The MDS-C1 stated, he has to do the search to determine the number of PI since the MDS assessment was done by another MDS Coordinator, not him. After searching the Treatment Administration Record (TAR) and the Nurse's Progress Notes, (NPN), the MDS-C1 verified there was only one PI, Stage 1, not two, Page 1 of 2 555657 555657 06/10/2025 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0641 I don't see the other location (body areas) for Stage 1. Level of Harm - Minimal harm or potential for actual harm 2. Record review of the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Residents Affected - Few In an interview on 6/10/25, at 10:20 AM, with the WCN 1, WCN 1 stated, Resident 2 has three (3) PIs: on the left shin, left heel, and left lateral malleolus (bony knob on the side of the ankle), it's now healing. Record review of the H&P dated 5/15/25 indicated, the diagnoses that included acute blood loss, upper gastrointestinal hemorrhage (bleeding occurs in the upper parts of the digestive tract), and chronic ulcer of left lower leg. In a concurrent record review and interview, on 6/10/25, at 11:30 AM, with the MDS-C1, the admission MDS dated [DATE], was reviewed. The MDS, section M0300, Current number of Unhealed Pressure Ulcers/injuries at Each Stage, section C. Stage 3 indicated, the Number of Stage 3 PI was marked four (4) in the box next to it. The MDS-C1 stated he has to search the TAR and the NPN to determine the number of the PI since another MDS coordinator has done the assessment and after searching the TAR and the NPN, the MDS-C1 verified, the resident has three (3) PI, Stage 3, not four (4) as documented. In an interview on 6/10/25 at 2:20 pm with the Facility Administrator -in Training (FA-iT), FA-iT stated, the facility followed the Resident Assessment Instrument (RAI,) Manual (a comprehensive process used to evaluate a resident's functional status, strengths, and needs). Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/24 indicated, Steps for Assessment: 1. Perform head-to-toe assessment. Conduct a full body skin . (sacrum, buttocks, heels, ankles, etc. 2. For the purposes of coding, determine that the lesion being assessed is primarily related to pressure and that other conditions have been ruled out. 555657 Page 2 of 2