Inaccurate MDS Documentation for Resident with Level II PASRR
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the preadmission screening and assessment resident record (PASRR) for a resident with a serious mental illness and/or intellectual disability. Specifically, Resident #24, who had diagnoses of Vascular Dementia, Parkinson's, and altered mental status, was not correctly documented in section A1500 of the MDS. The resident's annual MDS indicated no mental health diagnoses, despite having a Level II PASRR evaluation that identified a serious mental illness. This discrepancy was observed during a survey, where the MDS nurse initially denied the presence of a Level II PASRR for Resident #24 but later confirmed it upon review. The MDS nurse acknowledged the importance of accurate MDS coding for ensuring appropriate care and referenced the Resident Assessment Instrument (RAI) manual for guidance. The surveyor's review revealed that the facility did not have a specific MDS policy in place. The Assistant Administrator and the MDS nurse were asked to provide documentation from the RAI manual concerning section A1500, which was eventually provided. The failure to accurately document the resident's mental health status in the MDS had the potential to affect six residents with a Level II PASRR. This deficiency highlights a significant lapse in the facility's assessment and documentation processes, which are crucial for delivering appropriate care to residents with serious mental illnesses or intellectual disabilities.
Penalty
Resources
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Surveyors found that MDS assessments were inaccurately coded for two residents. For one resident with dementia and mood and anxiety disorders, bed handrails ordered and used for mobility were coded on the MDS as a daily physical restraint, despite no restraint assessment or care plan documentation and observation showing the rails did not restrict movement. For another resident with Wernicke’s encephalopathy, psychotic disorder with hallucinations, and dementia, documentation showed the pneumococcal vaccine was offered and declined, but the MDS recorded that the resident was not up to date because the vaccine had not been offered. Facility nursing leadership and the MDS nurse confirmed both MDS assessments were coded inaccurately.
A resident with severe cognitive impairment and multiple diagnoses was documented in medical and dental assessments as having natural teeth with missing teeth and no dentures, while staff interviews revealed the resident actually had partial dentures. This inconsistency between staff knowledge and assessment documentation resulted in a deficiency related to inaccurate resident assessments.
A resident with diabetes and anxiety was documented in MDS assessments as having no dental issues, but was observed to be without natural upper teeth and reported losing teeth since admission without being offered dental assistance. Interviews with the MDS RN, an LPN, and the DON confirmed the inaccuracy of the resident's dental status in the MDS.
A resident was admitted with complex medical conditions and hospital records indicating buttock wounds, but the facility's admission assessment did not document these wounds. The MDS nurse, relying solely on hospital documentation and without conducting a personal assessment, recorded pressure injuries that were not present according to the facility's clinical evaluation. The discrepancy between hospital and facility findings was not addressed before completing the MDS assessment.
The facility did not accurately complete MDS 3.0 assessments for two residents, resulting in incorrect documentation of discharge status and failure to record multiple vascular wounds and pressure ulcers. These deficiencies were confirmed through medical record review and staff interviews.
A resident with dementia and a history of wandering and aggressive behaviors was admitted to the secure/memory care unit without an assessment to determine appropriateness for placement. The DON confirmed that the required assessment was not completed prior to admission, and only after placement was the resident's severe mentation impairment and exit-seeking behavior documented. This deficiency was identified during a complaint investigation.
Inaccurate MDS Coding for Restraint Use and Pneumococcal Immunization
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments related to restraint use and immunization status. For one resident with dementia, mood disorder, and anxiety disorder, the medical record showed a physician’s order for bilateral handrails to promote bed mobility due to weakness, with checks every shift. The MDS assessment section P for this resident coded bed rails as a physical restraint used daily. However, the care plan did not document any restraint use, and the medical record did not contain a restraint assessment. Observation showed the bed had two small handrails at the top on each side, used for bed mobility, which did not inhibit the resident’s movement in or out of bed or otherwise restrain the resident. Facility staff, including the ADON and MDS nurse, confirmed the handrails were ordered for mobility and were not assessed as restraining the resident, indicating the MDS coding was inaccurate. For another resident with Wernicke’s encephalopathy, psychotic disorder with hallucinations, and dementia, the vaccine consent form documented that the resident was offered and declined the pneumonia vaccine. Despite this, the MDS assessment indicated the resident was not up to date with the pneumonia vaccine because it had not been offered. During interview, the ADON and MDS nurse confirmed that the pneumonia vaccine had been offered and declined, and that the MDS assessment had been coded inaccurately. These findings show that the facility failed to ensure MDS assessments accurately reflected the residents’ status regarding both restraint use and immunization history, as required by the accuracy of assessments regulation.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #11 on 03/26/2026. It was determined that there were no negative effects related to the lack of "Side Rail Assessment"/Grab Bar Evaluation. DON completed an assessment for the need and use of bilateral handrails to promote bed mobility due to weakness on 03/26/2026. It was determined that the bedrail is being used for promoting bed mobility not being used in a way that prevents or restrains Resident #11 from normal daily functioning. LNHA notified Resident #11's primary care provider on 03/26/2026, of findings noted during Annual Survey and that no negative effects were identified during assessment/observation related to the lack of "Side Rail Assessment"/Grab Bar Evaluation documentation. MDS Nurse corrected Resident #11's MDS on 03/20/2026 to reflect that his bed rails were no longer being used. On or before 4/30/2026, DON/Designee will ensure that other residents residing in the facility and using bedrails have a "Side Rail Assessment"/Grab Bar Evaluation completed to verify that bedrails are being utilized to promote mobility and in no way prevent/restrain a person from from normal daily function(ing). Assessment/evaluation by nursing/therapy will establish the use of which side or bilateral grab bars for mobility purposes. All residents will have care plan in place reflecting the accurate use of grab bar for mobility purposes. DON completed a head-to-toe physical assessment/observation on Resident #20 on 03/26/2026. It was determined that there were no negative effects related to the lack of documentation or related to the documentation discrepancy regarding the Pneumococcal vaccination (nursing documentation reflects that the vaccine was refused, but the MDS documentation describes that it was not offered) identified during Annual Survey. LNHA notified Resident #20's primary care provider on 03/36/2026, of findings noted during Annual Survey and that no negative effects were identified during assessment/observation related to the documentation discrepancy regarding the Pneumococcal vaccination (nursing documentation reflects that the vaccine was refused, but the MDS documentation describes that it was not offered). Primary care provider acknowledged the documentation discrepancy pertaining to the Pneumococcal vaccination. No new orders were provided. On or before 4/30/2026, DON/Designee will review the medical records of like residents residing in the facility to ensure that consents and care plan documentation aligns and that Pneumococcal vaccinations are administered per orders. On or before 04/30/2026, DON/Designee will provide education to licensed nursing personnel (including MDS nursing staff) regarding the following: 483.20(g)(h)(i)(j) Accuracy of F 0641 Assessments §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. §483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. §483.20(i) Certification. §483.20(i)(1) A registered nurse must sign and certify that the assessment is §483.20(i) (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. §483.20(j) Penalty for Falsification. §483.20(j) (1) Under Medicare and Medicaid, an individual who willfully and knowingly- (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. Also, on or before 04/30/2026, DON/Designee will provide education to licensed nursing personnel (including MDS nursing staff) explaining that: DON/MDS/Designee will review nursing documentation when completing MDS assessments to ensure that accurate coding is reflected in the MDS coding, specifically when a resident is using grab bars as a mobility device (not a restraint) and/or Pneumococcal vaccinations are offered/provided/declined. Discrepancies should be addressed with the Director of Nursing prior to coding by the MDS coordinator. On or before 04/30/2026, DON/Designee will compile a list of like residents who have bed rails. On or before 04/30/2026, DON/Designee will review the compiled list of like residents who have bed rails and ensure there is a current and accurate "Side Rail Assessment" documented. On or before 04/30/2026, DON/Designee will ensure that care plans and physician orders accurately reflect the use of bedrails and results from the "Side Rail Assessment." On or before 04/30/2026, DON/Designee will review MDS assessment for residents using bedrails to ensure accurate data has been coded and reported regarding the use and reasoning of use of bedrails. On or before 04/30/2026, DON/Designee will compile a list of residents, and their Pneumococcal vaccination status is. On or before 04/30/2026, DON/Designee will complete a complete audit to ensure that Pneumococcal vaccination statuses are accurately reflected in the medical record (i.e. consents, care plans). On or before 04/30/2026, DON/Designee will perform a complete audit to review most recent MDS assessment to ensure that MDS assessment accurately reflects the resident's Pneumococcal vaccination status. QAA. This audit will list the resident identifier (facility identifier), if they utilize bedrails, date of their last "Side Rail Assessment" why they utilize bed rails, and ensure accurate documentation is reflected in physician orders, care plan, and the recent MDS assessment. QAA. This audit will list resident identifier (facility identifier), the status of their Pneumococcal vaccination (offered, administered, declined, etc.), and ensure that this information is accurately reflected in the care plan and recent MDS assessment.
Failure to Complete Accurate Dental Assessments
Penalty
Summary
The facility failed to ensure accurate assessments were completed for a resident with multiple diagnoses, including psychotic disorder with delusions, Parkinson's disease, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies. Medical record review showed that nursing admission and dental assessments consistently documented the resident as having natural teeth with missing teeth and no dentures. However, during staff interviews, a CNA reported that the resident had partial dentures, which was confirmed by the unit manager upon review of the assessments. The Minimum Data Set (MDS) assessment also indicated the resident had no broken or loosely fitting dentures and no mouth or facial pain, discomfort, or difficulty chewing. This discrepancy between staff knowledge and documented assessments led to the deficiency.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident out of four reviewed. A resident admitted with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety was documented in quarterly MDS assessments as having no oral or dental issues. However, observation revealed the resident was without natural upper teeth, and the resident reported losing several teeth since admission and not being offered assistance to see a dentist. Interviews with the MDS RN and an LPN confirmed uncertainty and inaccuracy regarding the resident's dental status, and the Director of Nursing acknowledged the MDS assessment did not accurately reflect the resident's oral or dental condition.
Inaccurate Admission MDS Skin Assessment Due to Unresolved Documentation Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of an admission Minimum Data Set (MDS) skin condition assessment for one resident. Upon review, the resident was admitted with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Hospital discharge documentation indicated the presence of a right buttock wound and a left buttock deep tissue injury. However, the facility's admission wound assessment, completed by the Director of Nursing (DON), documented only a surgical incision to the abdomen and a stage two pressure ulcer of the left axilla, with no mention of wounds to the buttocks. The admission MDS assessment, completed by an MDS Registered Nurse who had not personally assessed the resident, recorded a stage two pressure ulcer and a deep tissue injury based solely on hospital documentation. During interviews, the MDS nurse admitted uncertainty about how to proceed when hospital records and clinical assessments did not align, as she was still in training. Subsequent observation and interviews confirmed the absence of pressure ulcers or deep tissue injuries on the buttocks at admission. The facility's policy required interdisciplinary participation in resident assessments, but the discrepancy between hospital and facility findings was not resolved prior to completing the MDS assessment.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately for two residents. For one resident, the MDS assessment indicated 'discharge return anticipated' after a hospital transfer, but the resident did not return to the facility. This error was confirmed by the MDS nurse during an interview. For the second resident, the initial nursing evaluation upon readmission did not address multiple vascular wounds to the left foot, and the five-day MDS assessment failed to document these wounds. Additionally, the resident's skin and wound evaluation noted an unstageable pressure ulcer on the right heel, but the assessment lacked wound measurements. Further review of the five-day MDS assessment for the second resident showed inconsistencies regarding cognitive status and assistance needs, and it did not address vascular wounds to the right toes. The MDS coordinator confirmed that the assessments did not reflect all existing wounds. These deficiencies were identified through medical record review and staff interviews during a complaint investigation.
Failure to Complete Assessment Prior to Secure Unit Placement
Penalty
Summary
The facility failed to complete an assessment prior to placing a resident on the secure/memory care unit. Record review showed that the resident was admitted with multiple diagnoses, including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. The care plan identified the resident as an elopement risk due to behaviors such as pacing the halls and wandering into other resident rooms, and included interventions like checking the secure tech bracelet and encouraging family involvement. However, there was no evidence in the medical record that an assessment was conducted to determine the appropriateness of placement on the secure unit before admission. Interview with the DON confirmed that the assessment was not completed prior to the resident's admission to the secure unit. A functional assessment was only completed after the resident was already on the unit, which documented severe mentation impairment, uncooperative and resistive behaviors, wandering, verbal and physical abuse, social inappropriateness, and exit-seeking. The resident had a history of attempts to exit home, aggression, and had recently attempted to exit the building, triggering the alarm. This deficiency was identified during a complaint investigation.
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