Health inspection·July 10, 2023

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 ensure assessments accurately reflected the each resident's status for 2 of 6 residents (Resident #2 and Resident #6) reviewed for accuracy of assessment . Residents Affected - Few The facility failed to ensure Resident #2 and Resident #6's MDS assessment correctly noted their behaviors. This failure could place residents at risk for not receiving care and services to meet their needs. Findings include: 1. A record review of Resident #2's face sheet, dated 07/06/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's had diagnoses which included Chronic Diastolic Congestive heart failure (a condition where the lower left chamber of the heart is not able to fill properly with blood during the diastolic phase, reducing the amount of blood pumped out to the body), Schizophrenia (delusions (false beliefs), hallucinations (seeing or hearing things that don't exist), unusual physical behavior, and disorganized thinking and speech and Type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Resident #2 was discharged to the hospital on [DATE]. A record review of Resident #2's admisson MDS , section E, dated 06/26/23, revealed no behaviors were exhibited in the 7-day look-back period. No behavior of rejection of care had occurred during that time. A record review of Resident #2 care plan, last revised on 06/20/23, revealed he required secure unit placement related to being an elopement risk. Resident #2 had poor impulse control, on 06/19/23. Resident #2 made a sexual comment to the aide and yelled loudly. On 06/20/23 Resident #2 refused incontinent care. The interventions included educating the resident regarding the outcome of not complying. Give Resident #2 a clear explanation of care activities and encourage Resident #2 to make his own choices and remain independent during care. 2. A record review of Resident #6's face sheet, dated 07/10/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Dementia (a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with your daily life), Delusional disorder, and Major depressive disorder . Resident #2 was located on the facility's secure unit. A record review of Resident #6's quarterly MDS, dated [DATE], revealed section E, for behaviors, Page 1 of 2 675032 675032 07/10/2023 Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104

F 0641 reflected no delusions and no behaviors were documented. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #6's care plan, dated 03/25/22, revealed the resident was a wander and elopement risk. No other behaviors were noted on the care plan. Residents Affected - Few A record review of Resident#6's progress notes from 05/26/23 to 06/02/23 reflected the following: 06/02/23- Was a behavior observed? Yes, completed by Nurse D 06/01/23- Was a behavior observed? Yes, completed by Nurse D 05/31/23- Was a behavior observed? Yes, completed by Nurse D 05/30/23- Was a behavior observed? Yes, completed by Nurse D 05/29/23- Was a behavior observed? Yes, completed by Nurse D An interview with the SW on 07/10/23 at 11:09 AM revealed she completed section E of the residents MDS. She completed the section based on the 7-day look-back period for the residents. She would review the records of the residents before completing the section. She was not aware of Resident #2 or Resident #6 displaying behaviors within the look-back period . The SW revealed she had not documented behaviors for each resident , though records reflected that Resident #2 and Resident #6 had behaviors. The SW stated she reviewed the records and had not seen any documentation of behaviors for each of the residents. An interview with the ADM on 07/10/23 at 12:52 PM revealed Resident #2's care plan reflected there had been behaviors within the look-back period. She had no knowledge of why the SW had not documented correctly on the MDS. Resident #6 had behaviors, and the SW should have completed the MDS to reflect those behaviors. The ADM stated the facility did not have a policy regarding MDS accuracy, however, the facility followed the RAI manual for completing MDS assessments. An interview on 07/10/23 at 2:34 PM with Nurse D, revealed Resident #6 had behaviors non-stop. The nurse stated Resident #6's behaviors included wandering into other residents' rooms. Resident #6's behaviors also included exit-seeking throughout the secure unit. Nurse D stated Resident #6 would often be redirected after attempting to push other residents that were in the wheelchair, to be helpful . Record review of the CMS RAI manual, dated 10/19, reflected Steps for Assessment 1. Review the resident's medical record for the 7-day look-back period. 2. Interview staff members and others who have had the opportunity to observe the resident in a variety of situations during the 7-day look-back period. 3. Observe the resident during conversations and the structured interviews in other assessment sections and listen for statements indicating an experience of hallucinations, or the expression of false beliefs (delusions). 675032 Page 2 of 2