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F0641
E

Inaccurate MDS Assessments for Residents on Hospice and Special Treatments

Grass Valley, California Survey Completed on 08-22-2025

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 accurate completion of Minimum Data Set (MDS) assessments for four residents. For one resident with sleep apnea, the MDS was incorrectly marked as receiving an invasive mechanical ventilator, despite documentation and staff interviews confirming the resident only used a C-PAP machine at bedtime and had never been on a ventilator. The MDS Coordinator acknowledged the error, and the Director of Nursing confirmed that such inaccuracies could impact the quality of care provided. Another resident, admitted with severe cognitive impairment and a terminal prognosis, had a Certification of Terminal Illness and physician orders indicating hospice care for end-stage dementia. However, the MDS did not reflect the resident's terminal status or hospice care, as confirmed by the MDS Coordinator, who admitted to miscoding the assessment. Similarly, a third resident with a terminal diagnosis and on hospice care was not identified as such in two separate MDS assessments, and the MDS also failed to indicate a life expectancy of less than six months, contrary to medical documentation. A fourth resident, admitted under hospice services for dementia with severe agitation, had multiple MDS assessments that did not consistently reflect the terminal prognosis or hospice care status. The MDS Coordinator acknowledged that these assessments contained conflicting and inaccurate information, which could affect care planning. Facility policy requires that qualified staff conduct accurate assessments reflective of each resident's status, but this was not followed in these cases.

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