Health inspection·November 9, 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 complete an accurate assessment of resident's functional capacity for 1 (Resident #1) out of 3 residents reviewed for MDS assessment. Residents Affected - Few Facility failed to document stage II pressure ulcer in Resident #1's MDS dated [DATE]. This failure placed residents at risk of not receiving adequate services and/or care. Findings included: Record review of face sheet revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His diagnoses included Hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), Acute posthemorrhagic anemia (a condition which a person quickly loses a large volume of circulating blood), Dysphagia (difficulty swallowing), Gastro-esophageal reflux disease (A chronic disease that occurs when stomach acid flows into the food pipe and irritates the lining), Hyperlipidemia (A condition in which there are high levels of fat particles in the blood), Traumatic subarachnoid hemorrhage (bleeding inside the brain), Hypertensive urgency (A hypertensive urgency is a clinical situation in which blood pressure is very high with minimal or no symptoms, and no signs or symptoms indicating acute organ damage). Review of admission record dated 10/12/2023 revealed Resident #1 was admitted with stage 2 pressure ulcer. Review of care plan dated 10/17/2023 revealed Resident #1 had pressure ulcer with goal to prevent and heal the pressure sore and skin breakdown. Review of TAR (Treatment Administration Record) for the month of October and November 2023 revealed documentation of pressure ulcer treatment for Resident #1. Review of MDS dated and signed as completed on 10/17/2023, section M revealed Resident #1 had no pressure ulcer. On 11/09/2023 at 3:22pm in an interview with the DON, he stated the MDS record was completed by the MDS nurse who was the one responsible for completing the MDS care assessment. On 11/09/2023 at 3:58 pm in an interview with the MDS nurse, she stated the MDS was started on the 10/12/2023 when the resident was admitted . The MDS was signed complete on 10/17/2023 indicating the assessment of the resident was done and completed. She stated she was not aware of the resident Page 1 of 2 675229 675229 11/09/2023 Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few having any wound or pressure ulcer at the time of the assessment. She stated she became aware of the pressure ulcer about two weeks ago. She also stated she did not correct the MDS at that time because she did not know how to edit or correct the MDS record because she was still in training by the Corporate MDS Nurse. When asked why she did not ask the Director of nursing or the Corporate MDS Nurse training her how she could fix the MDS, she stated mmm .I don't know. She said she did not ask anyone because she did not know she had to ask someone. She stated MDS record was an important part of resident's information, it should contain accurate information about residents, and it helped to know the area of need that the patient was being treated for. Record review of facility policy dated November 2019 titled 'Certifying Accuracy of the Resident Assessment' revealed in part, The information on the assessment reflects the status of the resident during the period for that assessment .The resident assessment coordinator is responsible for ensuring that MDS has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator. 675229 Page 2 of 2