Health inspection·November 25, 2024

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 interview and record review, the facility failed to accurately assess one of four sampled residents (Resident 1) when the most recent MDS (Minimum Data Set, an assessment tool) did not identify the resident had behavior issues during the seven days look-back period. Residents Affected - Few This failure had the potential for ineffective care planning and risk for unmet care needs for Resident 1. Findings: Resident 1 was admitted to the facility in October of 2024 with diagnoses that included mental and psychological issues. A review of Resident 1's Change in Condition Note (CCN), dated 11/3/24, indicated, Situation: The Change In Condition/s reported on this CIC [change in condition] Evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis) .Behavioral Status Evaluation: Physical aggression .Nursing observations, evaluation, and recommendations are: Pt [patient] was in a Pt to Pt altercation with another resident. CNA [Certified Nursing Assistant] observed pt punch 203A in the face during smoke break. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 had mild cognitive (ability to remember, think, and reason) impairment. The MDS section E (section in the MDS that details behaviors during a seven day look-back period) indicated Resident 1 was assessed to not have physical behaviors towards others or hallucinations during the look-back period. A review of Resident 1's Medication Administration Record (MAR), dated 11/26/24, indicated Resident 1 received Haloperidol (an antipsychotic medication) five milligram (a unit of measurement) oral tablets three times daily from 11/1/24 to 11/6/24. The MAR indicated, Give 1 tablet by mouth three times a day for [diagnosis] m/b [manifested by] auditory hallucinations. During a concurrent interview and record review on 11/25/24 at 11:47 a.m., with the MDS Coordinator 1 (MDSC 1), Resident 1's MDS Section E, dated 11/9/24, was reviewed. MDSC 1 confirmed Resident 1's medical record indicated he was exhibiting auditory hallucinations and physical behaviors during the look-back period and verified Resident 1's behaviors were not marked in the MDS Section E. The MDSC 1 indicated having an accurate MDS was important to present accurate resident information and care planning more effective. During a concurrent interview and record review on 11/25/24 at 12:04 p.m., with the MDSC 2, Resident 1's MDS section E dated, 11/9/24, was reviewed. MDSC 2 confirmed that Resident 1's MDS section E Page 1 of 2 555744 555744 11/25/2024 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

F 0641 was not accurate due to Resident 1's history of physical behaviors and auditory hallucinations. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/25/24 at 12:15 p.m., with the Director of Nursing (DON), the DON indicated it is important for the MDS assessments to be accurate, since it dictates the care planning process for residents. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 7/20, the P&P indicated, All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. 555744 Page 2 of 2