Stay Ahead of Compliance with Monthly Citation Updates


In your State Survey window and need a snapshot of your risks?

Survey Preparedness Report

One Time Fee
$79
  • Last 12 months of citation data in one tailored report
  • Pinpoint the tags driving penalties in facilities like yours
  • Jump to regulations and pathways used by surveyors
  • Access to your report within 2 hours of purchase
  • Easily share it with your team - no registration needed
Get Your Report Now →

Monthly citation updates straight to your inbox for ongoing preparation?

Monthly Citation Reports

$18.90 per month
  • Latest citation updates delivered monthly to your email
  • Citations organized by compliance areas
  • Shared automatically with your team, by area
  • Customizable for your state(s) of interest
  • Direct links to CMS documentation relevant parts
Learn more →

Save Hours of Work with AI-Powered Plan of Correction Writer


One-Time Fee

$49 per Plan of Correction
Volume discounts available – save up to 20%
  • Quickly search for approved POC from other facilities
  • Instant access
  • Intuitive interface
  • No recurring fees
  • Save hours of work
F0641
B

Inaccurate MDS Assessments for Diagnoses and Medication Use

Santa Ana, California Survey Completed on 05-13-2025

Penalty

No penalty information released
tooltip icon
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect coding of active diagnoses and medication use. For one resident, the MDS assessment did not reflect active diagnoses of hypertension, hyponatremia, and depression, despite medical records and physician orders indicating these conditions. The assessment also failed to accurately document the use of antidepressant medication and incorrectly recorded the date of the last attempted gradual dose reduction (GDR) for antipsychotic medication. The MDS Coordinator confirmed these discrepancies, noting that some orders may have been carried over from a hospital stay without proper medical indication and that laboratory results were misinterpreted when coding the diagnosis of hyponatremia. Another resident's MDS assessments were also found to be inaccurate, as they did not include documented diagnoses of anxiety disorder and major depressive disorder, despite these being present in the resident's medical history and physician notes. The assessments showed the resident was cognitively intact but failed to code the relevant psychiatric diagnoses in Section I of the MDS. The MDS Coordinator acknowledged that these diagnoses should have been included as soon as they were documented by the physician or on the next assessment. Interviews with the MDS Coordinator, Administrator, and Director of Nursing confirmed the findings and acknowledged the inaccuracies in the MDS assessments. These failures had the potential to impact the provision of necessary care and services to meet the residents' needs, as the assessments did not accurately reflect their current medical conditions and medication use.

An unhandled error has occurred. Reload 🗙