Health inspection·March 12, 2025

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal 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's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS System including a subset of items upon a resident's transfer, reentry, discharge, and death for 2 of 2 residents (Residents #16 and #115) reviewed for MDS assessments. Residents Affected - Some 1. The facility failed to transmit to the CMS system Resident #16 's discharge MDS assessment, dated 01/10/25. 2. The facility failed to transmit to the CMS system Resident #115 's discharge MDS assessment, dated 11/16/24. These failures could place residents at risk of not having their assessments completed and submitted in a timely manner and having their Medicaid payments and/or services interrupted. Findings include: 1. Record review of Resident #16's face sheet, dated 03/13/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 01/11/25. Resident #16 had diagnoses which included right femur fracture (a break in the thigh bone), multiple sclerosis (numbness, weakness, trouble walking, and vision changes caused by a breakdown of the nerves protective covering), and hypertension (high blood pressure). Record review of Resident #16's electronic health records, under the MDS tab, indicated the discharge MDS was dated 11/19/24. The discharge MDS status indicated the assessment was transmitted and accepted on 03/12/25. 2. Record review of Resident #115's face sheet, dated 03/13/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/06/24. Resident #115 had diagnoses which included surgery on the digestive system, ileus (slowing of the digestive tract that can prevent the passage of food), sepsis (blood infection), and dementia (loss of cognitive function that affects memory, thinking and social abilities). Record review of Resident #115's electronic health records, under the MDS tab, indicated the discharge MDS was dated 11/06/24. The discharge MDS status indicated the assessment was transmitted and accepted on 03/12/25. Page 1 of 2 676443 676443 03/12/2025 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0640 Level of Harm - Potential for minimal harm Residents Affected - Some During an interview on 03/12/25 at 2:04 p.m., MDS Nurse A said she and MDS Nurse B were responsible for ensuring the MDS assessments were completed and transmitted within a 14-day timeframe. MDS Nurse A said the discharge MDS status for Residents #16 and #115 were listed as Ready to Export, which meant they were completed but were not transmitted. MDS Nurse A said she and MDS Nurse B were unable to submit Residents #16 and #115 MDS within the 14 day timeframe because they were both out sick . MDS Nurse A said the discharge MDS for Residents #16 and #115 were not transmitted by the 14th day but will submit them today. MDS Nurse A said it was important to complete and transmit the MDS assessments timely because they affected quality of care measures and payments. MDS Nurse A said they did not have a policy and followed the RAI guidelines . During an interview on 03/12/25 at 2:34 p.m., the Administrator said she was not aware Residents #16 and #115's MDS were not transmitted. The Administrator said it was the responsibility of the MDS nurses to complete and transmit the MDS timely. Record Review of the CMS RAI Version 3.0 Manual, dated October 2024, indicated, in Chapter 2, page 2-39 .09. Discharge Assessment-Return Not Anticipated (A0310F) . Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after 676443 Page 2 of 2