The Pavilion At Ocean Point
THE PAVILION AT OCEAN POINT in SAN DIEGO, CA — inspection on September 17, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review Resident 2's Minimum Data Set (MDS-a clinical assessment tool) dated 8/25/25, section I5600 indicated an x next to malnutrition. An interview and joint record review was conducted on 9/17/25 at 10:41 A.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents).
The MDSN reviewed Resident 2's MDS.
The MDSN stated physician documentation was required to code malnutrition in section I5600.
The MDSN stated she provided a query titled, ICD-10-CM MD QUERY for the physician to sign.
The MDSN stated the form served as supporting documentation to code malnutrition in the MDS.
The MDSN further stated the query for Resident 2 had not been signed by the physician and she coded malnutrition in Resident 2's MDS. An interview was conducted on 9/22/25 at 9:12 A.M. with the Director of Nursing (DON).
The DON stated physician documentation was needed to accurately code the MDS because the MDS was sent to CMS (Center for Medicare and Medicaid Services- oversees the nation's health care system) for billing. A review of the facility's policy and procedure (P&P) titled, RAI [Resident Assessment Instrumentmanual for completing the MDS] Process, revised on 10/4/16 was conducted.
The P&P indicated, The Facility will utilize the Resident Assessment Instrument [RAI] process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual. A review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 was conducted.
Chapter 1.2 page seven of the User's Manual indicated the Resident Assessment Instrument (RAI) consisted of the MDS.
The User's Manual chapter 1.2, page eight indicated, .The RAI process has multiple regulatory requirement.Federal regulations.require that (1) the assessment accurately reflects the resident's status.
Furthermore chapter 5.5, page 668 of the User's Manual indicated, .the MDS must be accurate as of the ARD [Assessment Reference Date].
Minor changes in the resident's status should be noted in the resident's record.in accordance with standards of practice and documentation.
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.
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