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F0641
D

Inaccurate MDS Coding of Resident Wandering Behavior

Alameda, California Survey Completed on 05-02-2025

Penalty

No penalty information released
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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 the Minimum Data Set (MDS) assessment for one resident, specifically in section E, which addresses wandering behavior. Observation showed the resident wandering the hallways with a walker and entering other residents' rooms. During interviews, a CNA confirmed that the resident frequently wandered, entered other rooms, turned off lights, and became agitated when redirected. However, a review of the resident's annual MDS assessment indicated that wandering behavior was coded as not exhibited. The Social Services Director, responsible for completing this section of the MDS, acknowledged that the wandering behavior was not coded accurately.

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