Health inspection·June 19, 2025

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 within 14 days after a facility completed a resident assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 15 residents (Resident #34) reviewed for MDS transmission. Residents Affected - Few The facility failed to transmit a completed Quarterly MDS assessment for Resident #34 within 14 days of completion. This failure could place residents at-risk of not having their assessment/s completed timely, which could result in denial of services and or denial of payment for services. Findings include: Record review of Resident #34's admission Record revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #34 had diagnoses which included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), Alzheimer's Disease with late onset (a progressive disease that destroys memory and other important mental functions), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete paralysis and weakness on one side of the body caused by damage to brain after a blood clot or stroke), dysphagia (difficulty swallowing foods or liquids), type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy) and gastrostomy status (surgical procedure that creates an opening through the abdominal wall into the stomach for the purpose of feeding or receiving nutrition). Record review of Resident #34's Quarterly MDS assessment, dated 1/14/25, revealed the assessment was signed as completed on 1/15/25 and accepted by the CMS system on 1/31/25. The date of 1/31/25 was highlighted in red. Telephone interview on 6/18/25 at 1:01 PM with the Director of Reimbursement, she said the red highlighted date of 1/31/25 meant that the Quarterly assessment was accepted and or transmitted late. She said if the ARD was 1/14/25 and the assessment was signed as completed on 1/15/25, but the accepted transmission date was on 1/31/25, that was a 16- day instead of 14-day transmission timeframe and 16 days would be late. The Director of Reimbursement said the completion, submission, and transmission of any facility MDS assessments were the responsibility of the facility MDS Coordinator, but the facility was without an on-site MDS Coordinator for many months. She said the facility used the RAI as the policy and procedure for completion, accuracy, submission, and transmission of MDS Page 1 of 2 676304 676304 06/19/2025 Creekside Village 914 N Brazosport Blvd Richwood, TX 77531

F 0640 assessments. Level of Harm - Minimal harm or potential for actual harm Interview on 6/18/25 at 1:03 PM with the Corporate VP of Operations, she said the facility did not have an assessment policy and the facility used the RAI Manual for assessments. She said the expectation of the facility was for the RAI Manual to be followed, and moving forward, the responsibility for MDS assessments at the facility were the MDS Coordinators. Residents Affected - Few Interview on 6/18/25 at 1:12 PM with MDS Coordinator A, she said she was not employed at the facility when Resident #34's Quarterly MDS assessment was completed back on 1/15/25. MDS Coordinator A said they had only worked at the facility since 6/2/25 and said the facility used the RAI Manual as its policy and procedure completing MDS assessments. She said according to the RAI Manual Resident #34's 1/14/25 Quarterly MDS assessment, should have been transmitted by the 14th day and not the 16th day. MDS Coordinator A said they had been trained by the Director of Reimbursement. Follow up interview with MDS Coordinator A on 6/18/25 at 2:54 PM, they said Resident #34 could potentially not receive needed therapy or services due to assessments not being transmitted on time. She also said there could be a delay in reimbursement, or payments could be taken back by CMS if assessments were not completed, submitted, or transmitted correctly according to the RAI Manual. Record review of the CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment, revised 11/2019, revealed: 5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing. Assessment Transmission .All other MDS assessments must be 676304 Page 2 of 2