Health inspection·July 26, 2025

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 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for falls on 6/1/25 and 6/18/25.This failure could place residents at risk of receiving care and services to meet their needs. The findings included:Record review of Resident #1's face sheet dated 07/26/25 reflected Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 had diagnoses of dementia (a progressive decline in cognitive abilities, such as memory, thinking, language, and judgement that interferes with daily functioning and social interactions), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), repeated falls, muscle weakness, and abnormalities of gait (the manner or pattern of walking) and mobility. Record review of Resident #1's undated comprehensive care plan reflected: Resident #1 was at high risk for falls and had an unwitnessed fall on the following dates:6/1/25 I had an unwitnessed fall. Date Initiated: 04/29/2024 Revision on: 06/02/2025. 6/18/25 I had an unwitnessed fall. Date Initiated: 06/18/2025.Record review of Resident #1's Discharge MDS dated [DATE] revealed: Short-term memory problem and severely impaired cognitive skill.Dependent on assistance for all self-care and mobility.No falls since Admission/Entry or Reentry or Prior MDS Assessment.Record review of the facility's incident log dated 7/25/25 revealed that Resident #1 had un-witnessed falls on 6/1/25 and 6/18/25. No other information regarding the fall was noted on the facility log.During an interview on 7/26/25 at 1:15 p.m., ADON said she oversaw completing the MDS at discharge. She said the falls on 6/1/25 and 6/18/25 were not captured on Resident #1's discharge MDS. She said it was her fault. She said she must had overlooked the question and placed no. She said Resident #1 did have those falls and the falls should have been captured on the discharge MDS. She said she started doing MDS approximately 8 months ago, so she was still learning. She said she was not sure why the fall must be captured on the discharge MDS. She said that she would imagine due to quality measures, so it would show the fall occurred. She said a negative outcome for not capturing the falls on the discharge MDS, would have had more of an effect if the fall was a major fall and Resident #1 entered the facility. She said the ambulance staff and hospitals usually obtain the information during report not from the MDS. She said to her understanding, if a fall required sending out the resident to the hospital, the hospital did not receive the MDS information. She said the hospital received order summaries, MARs, MD orders, and transfer orders all in paper forms.During an interview on 7/26/25 at 2:08 p.m., DON said that the falls on June 1st and June 18th of this year (2025) for Resident #1 were not captured on the discharge MDS because the RAI questions had a look back period, but she was not sure when the look back time was. The DON researched and got back with surveyor then she said there was not a look back period for the falls that Resident #1 had in June 2025. The DON said the negative outcome for the falls if not captured on the MDS would be incorrect documentation. She said she was not sure how it would affect the RUG (a classification Residents Affected - Few Page 1 of 2 676214 676214 07/26/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few system used in skilled nursing facilities, to categorize residents based on their care needs and resource intensity which helps determine the level of care and associated costs for reimbursement purposes). Record review of CMS's RAI Version 3.0 Manual dated 10/2024, reflected section:J1800: Any falls since admission/entry or reentry or prior to Assessment.Coding instructions:Code 0, no: if the resident has not had any fall since the last assessment.Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior assessment.(J1900), whichever is more recent. 676214 Page 2 of 2