F641 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F641 less often than its own record predicts
Versus expected share0.92×
0.92 times the national share — cited less often here than elsewhere.
Share of California citations1.69%
Of every deficiency written in California in 2025, this is the portion that was F641.
California1.69%
National1.84%
Share of all citations that were F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F641 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
G · Actual harm, isolatedNovember 27, 2019
Based on interview and record review, the facility failed to update a resident's Minimum Data Set ((MDS) an assessment and resident care screening tool) and care plans after a resident had two falls to reflect the resident's care needs for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls and was identified by the facility as having a behavior of throwing herself to the floor was not assessed and considered as part Resident 1's plan of care to prevent falls and injuries during care. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 128) who was discharged home under the care of home health service (wide range of health care services that could be given at home) had the home health service accurately coded in the Minimum Data Set (MDS, a resident assessment tool) assessment dated [DATE]. This deficient practice resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 128 not receiving interventions to address specific care concerns. …
B · No harm, potential for minimal, patternAugust 13, 2026
Based on interview, medical record review, and P&P review, the facility failed to ensure the MDS assessment was accurate for one of three final sampled residents (Resident 93) reviewed for closed records. * The facility failed to accurately code the MDS assessment when Resident 93 was transferred to the acute care hospital. This failure provided the wrong information for the correct disposition of the resident. Findings: Review of the facility's P&P titled MDS Accuracy Policy & Procedure dated [DATE], showed the MDS assessments completed were accurate, complete and compliant. Accurate MDS assessments ensure proper care planning, regulatory compliance, and reimbursement integrity. Closed medical record review for Resident 93 was initiated on [DATE]. …
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