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
interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS, an
assessment tool) for one of three sampled residents (Resident 1), when Resident 1's MDS weight and
continence were inaccurately documented. Failure to accurately assess had the potential to compromise
the facility's ability to develop and implement interventions to meet the resident's needs.
Residents Affected - Few
Findings:
1. Review of Resident 1's medical record indicated the resident was admitted on [DATE] and had diagnoses
including femur fracture (a break in the thigh bone), sepsis (an extreme bodily response to an infection),
obesity (a disorder that involves having excessive body fat), and kidney disease.
Review of Resident 1's Weights and Vitals Summary indicated Resident 1 weighed 231.4 pounds (lbs, unit
of weight measurement) on 7/17/24. The Weights and Vitals Summary further indicated Resident 1 weighed
220.8 lbs on 7/22/24.
Resident 1's MDS, dated [DATE], was reviewed. Section K0200 was designated to document the resident's
most recent weight. The individual who completed the MDS documented that Resident 1 weighed 231 lbs.
During an interview and concurrent record review with the registered dietician (RD) on 8/22/24, at 12:40
p.m., the RD reviewed Resident 1's medical record and confirmed the resident's most recent weight was
220.8 lbs.
During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on
8/22/24, at 2:06 p.m., the MDSC confirmed Resident 1's MDS, dated [DATE], was not accurate. The MDSC
confirmed the individual who completed the MDS should have documented Resident 1's most recent
weight in section K0200.
The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment
Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2023, indicated for section
K0200, Base weight on most recent measure in last 30 days.
2. Resident 1's MDS, dated [DATE], was reviewed. Section H of the MDS was designated to indicate
whether the resident was continent (able to control urination and defecation) or incontinent (unable to
control urination and defecation). The individual who completed the MDS coded 0 to indicate Resident 1
was Always continent with both urination and defecation.
(continued on next page)
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
Page 1 of 2
Event ID:
055739
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055739
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Salinas Valley Post Acute
637 East Romie Lane
Salinas, CA 93901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident 1's Documentation Survey Report indicated from 7/21/24 to 7/27/24, Resident 1 was
incontinent with urination 15 times and was continent six times. The Documentation Survey Report further
indicated for the same time frame, Resident 1 was incontinent with defecation nine times and was continent
zero times.
During an interview and concurrent record review with the MDSC on 8/22/24, at 2:06 p.m., the MDSC
reviewed Resident 1's medical record and confirmed the resident was incontinent with both urination and
defecation from 7/21/24 to 7/27/24. The MDSC confirmed Resident 1's MDS, dated [DATE], was not
accurate. The MDSC stated the individual who completed the MDS should have indicated Resident 1 was
frequently incontinent with urination and always incontinent with defecation.
Review of the RAI Manual, dated 10/2023, indicated for section H, Code 2, frequently incontinent: if during
the 7-day look-back period, resident was incontinent of urine during seven or more episodes but had at
least one continent void [urination]. The RAI Manual further indicated, Code 3, always incontinent: if during
the 7-day look-back period, the resident was incontinent of bowel for all bowel movements [defecation] and
had no continent bowel movements.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055739
If continuation sheet
Page 2 of 2
