Health inspection·September 12, 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 ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #1 was coded on her Quarterly MDS for two falls without injury that occurred on 04/13/2024 and 04/22/2024. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated 09/12/2024, reflected Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 was noted to be on hospice services. Record review of Resident #1's Diagnosis Report, dated 09/12/2024, reflected Resident #1 was diagnosed with diffuse follicle center lymphoma (a widely spread type of cancer that develops inside the lymph nodes), had a history of falling, muscle weakness, and shortness of breath. Record review of facility report, Incidents By Incident Type, date range 04/06/2024 to 04/30/2024 reflected Resident #1 had unwitnessed fall incidents on 04/13/2024 at 09:00 a.m. and on 04/22/2024 at 07:00 a.m. Record review of Resident #1's Nursing Note, dated 04/13/2024, reflected Resident #1 was found sitting on the floor by a facility housekeeper. Resident #1 stated she was trying to get up from her big couch and her legs couldn't hold her and she slid to the floor. Resident #1 stated she felt fine and didn't hit her head or body but needed to get up to use the toilet. The nursing note reflected Resident #1 was assessed and found to have no apparent injuries. Record review of Resident #1's Nursing Note, dated 04/22/2024, reflected Resident #1 was found lying on the floor, laughing and awake, by the nurse. Resident #1 was able to indicate that she was fine. The nursing note reflected Resident #1 was assessed, neuro checks were started, and no apparent injuries were found. Record review of Resident #1's admission MDS, dated [DATE] reflected Resident #1 had a BIMS score of 13 indicating she was cognitively intact, and she required setup or clean-up assistance for her self-care and mobility needs, and supervision or touching assistance when walking. She used a walker. Her fall history on Admission/Entry or Reentry was noted as unable to determine with her having not Page 1 of 2 675437 675437 09/12/2024 Advanced Rehabilitation & Healthcare of Live Oak 8221 Palisades Drive Live Oak, TX 78233

F 0641 Level of Harm - Minimal harm or potential for actual harm had a fall in the last 2-6 months prior to admission/entry or reentry and no falls since admission/entry or reentry. Record review of Resident #1's State Optional MDS, dated [DATE] did not include a section on Resident #1's fall history. Residents Affected - Few Record review of Resident #1's Quarterly MDS, dated [DATE] reflected Resident #1 had a BIMS score of 12 indicating she had mild cognitive impairment, and she required setup or clean-up assistance for her self-care and mobility needs, and supervision or touching assistance when walking. She used a walker. Her fall history indicated she had not had any falls since admission/entry or reentry or the prior assessment. Resident #1's Quarterly MDS was signed as completed by the MDS Nurse on 06/17/2024 and Section J of the Quarterly MDS, which includes fall history, was signed as completed by the MDS Nurse on 06/14/2024. Record review of Resident #1's State Optional MDS, dated [DATE] did not include a section on Resident #1's fall history. During an interview on 09/12/2024 at 02:40 p.m., the MDS Nurse stated the facility employee that completed the MDS assessment and the regional nurse that oversaw the MDS assessments were responsible for the accuracy of the MDS assessments. The MDS Nurse stated that per the RAI (Resident Assessment Instrument) manual, the facility had to document a fall that occurred within the look back period. The MDS Nurse stated the look back period for falls ranges back to the last assessment. The MDS Nurse stated for Resident #1, she would have looked back to capture all of Resident #1's falls but falls are almost hardly ever missed when completing the assessments. The MDS Nurse stated she could not say why the information was not on the MDS assessment dated [DATE]. The MDS Nurse stated MDS assessment coding did not impact patient care because the facility nurses do not look at the MDS assessments. She stated falls with major injuries could impact facility scores for quality measures. During an interview on 09/12/2024 at 03:21 p.m., the ADMIN stated the MDS Nurse was responsible in ensuring the MDS Assessments were accurate. The ADMIN stated MDS Assessments affect the triggering of care needs for starting a care plan. She stated an incorrect MDS Assessment could affect the amount of care a resident receives because the care plan would be impacted. Record review of facility policy, MDS Completion, dated as reviewed 02/10/2021, revealed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary plan .e. Quarterly Assessment- completed using an ARD [Assessment Reference Date] no > [greater than] 92 days from the most recent prior quarterly or comprehensive assessment . h. Significant Correction of a Prior Quarterly Assessment- completed when the resident's overall clinical status was not accurately represented (i.e., miscoded) on the erroneous quarterly assessment and the error has not been corrected via submission of a more recent assessment. 675437 Page 2 of 2