Health inspection·October 25, 2023

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 reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 25 residents records reviewed for MDS assessments. (Residents #35) Residents Affected - Few The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #35. This failure could place residents at risk of not having their assessments transmitted timely. Findings included: Record review of Resident #35's admission record dated 10/25/23 indicated she was admitted on [DATE] with a discharge date of 06/26/23. Resident #35's diagnoses included joint replacement surgery. Record review of the MDSs for Resident #35 indicated the discharge MDS assessment was completed on 06/26/23. The discharge MDS assessment was marked current not transmitted or accepted. Record review of the nurse's notes from 06/16/23 to 06/26/23 indicated Resident #35 was discharged home on [DATE]. During an interview on 10/25/23 at 9:30 a.m., LVN C said she did not transmit Resident #35 discharge MDS assessment. She said she had received training on completing, preparing, signing and transmitting the MDS assessment to CMS. LVN C said Resident #35's MDS should have been sent so the resident records would be complete. During an interview on 10/25/23 at 9:45 a.m., the DON said when Resident #35 was discharged home, there should have been a discharge MDS completed and submitted. She said LVN C was responsible for transmitting and the used the RAI manual for the policy. During an interview on 10/25/23 at 10:00 a.m., the Administrator said he expected the discharge MDS assessments to be completed and transmitted. Review of the CMS's RAI Version 3.0 Manual obtained on 10/25/23 from the CMS website, https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2023.pdf indicated the following: CMS's RAI Version 3.0 Manual indicated . Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in (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 5 Event ID: 676444 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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)