The Pavilion At Ocean Point
Inspection Findings
F-Tag F0641
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDSa nursing assessment tool) for one of three sampled residents reviewed for MDS accuracy. (Resident 2)
This deficient practice resulted in providing inaccurate information to the Federal database (information maintained by the federal government).Findings:Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses including dysphasia (inability to communicate effectively) following cerebral infarction (stroke) according to the facility's admission Record. 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.
Residents Affected - Few
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
Event ID:
THE PAVILION AT OCEAN POINT in SAN DIEGO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN DIEGO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE PAVILION AT OCEAN POINT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.