Health inspection·March 20, 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 interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 5 residents (Residents #45) reviewed for MDS assessment accuracy. Residents Affected - Few The facility incorrectly coded Resident #45 as having a diagnosis of bipolar (extreme mood swings) on her MDS assessment. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of an admission Record for Resident #45 dated 3/19/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), mood disorder (affects your emotional state), hypertension (high blood pressure), and aphasia (a language disorder that affects how you communicate). There was no record of a diagnosis of bipolar. Record review of an admission MDS assessment for Resident #45 dated 2/13/2024 indicated she was rarely/never understood. She had an active diagnosis of bipolar disorder. Record review of a care plan for Resident #45 dated 2/9/2024 indicated she was at risk for impaired cognitive function/thought processes related to dementia. She had diagnosis of mood disorder with interventions to administer medications as needed. During an interview on 3/20/2024 at 8:55 AM, the MDS Coordinator said she had been employed at the facility for 1 1/2 years. She said she was responsible for completing the MDS assessments for the residents and the DON signed the assessments. She said they believed there was a glitch with one of the diagnosis codes for mood disorders related to dementia for Resident #45. She said the charting system automatically generated the diagnosis in the MDS assessments based off the information in the resident chart. She said Resident #45 did not have a diagnosis of bipolar. She said in the MDS assessments she could have manually deselected the bipolar diagnosis in the diagnosis list. She said she completed a modification of the admission MDS for Resident #45 on yesterday. She said there could a risk for getting funding for things that were not being treated. She said going forward she would have someone check behind her like the DON or Resource MDS that signed off on the assessments. During an interview on 3/20/2024 at 8:40 AM, the Resource MDS said she audited the MDS assessments for the facility at least twice a year. She said they reached out to their corporate staff to see if (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 675900 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe of Trinity Healthcare and Rehabilitat 808 S Robb Trinity, TX 75862 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)