Failure to Ensure RN Certification of MDS Assessments
Summary
The facility failed to ensure that each Minimum Data Set (MDS) assessment was certified as complete by a registered nurse (RN) for seven residents out of 26 reviewed. The assessments for these residents were instead signed by an LPN, identified as V17, who has been working in the facility for two years as the MDS/Care Plan coordinator. The MDS assessments are crucial for determining residents' activities of daily living, cognitive function, urinary/bowel function, current diagnosis, medication use, skilled therapy, and any falls. The State Operations Manual requires that each resident's assessment be coordinated by and certified as complete by an RN, which was not adhered to in these cases.
Penalty
The facility failed to ensure that MDS assessments for two residents were signed off by the RN MDS Coordinator, as required by RAI guidelines. An LPN completed and signed the assessments, but the necessary RN certification was missing. Interviews confirmed the oversight, with the current RN MDS Coordinator stating that all MDS assessments must be signed by an RN.
The facility failed to ensure that MDS assessments were certified by an RN for 13 residents, as required by policy. Instead, an LPN signed off on these assessments, which included Quarterly, Annual, and Admission assessments for residents with various medical conditions. The LPN confirmed signing these assessments over several months, and the CNO acknowledged the deviation from protocol, which requires an RN to verify the assessments.
A facility failed to transmit a resident's Discharge MDS to CMS within the required 30-day period. The resident, who had multiple diagnoses including metabolic encephalopathy and heart failure, was discharged to an Assisted Living Facility. The MDS Nurse admitted to forgetting to complete the discharge MDS, and the DON highlighted the importance of timely submissions for accurate reporting.
The facility failed to adhere to professional standards by falsifying and removing clinical records for two residents. One resident was restrained for a urine sample without a physician's order, resulting in bruising, and the documentation was removed. Another resident was pulled from a chair by another resident, but the incident was inaccurately documented as a fall. The DON denied recollection of the first incident and allegedly instructed staff to misreport the second to avoid police involvement.
A facility failed to accurately code the MDS for a resident with a non-pressure chronic ulcer and other medical conditions. Despite medical records confirming the presence of a skin ulcer, the MDS did not reflect this, leading to discrepancies in the resident's care documentation. Interviews revealed that the resident was aware of ongoing wound care, but staff were not consistent in coding practices, and the DON was unaware of the MDS coding process.
The facility failed to ensure accurate dating of resident assessments for three residents. The DON signed assessments as completed before all sections were finalized, with data input delays acknowledged by MDS #1. The DON altered dates to reflect when data and interviews were completed.
Failure to Ensure RN Sign-Off on MDS Assessments
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was signed off by the Registered Nurse (RN) MDS Coordinator as required by the Resident Assessment Instrument (RAI) guidelines. Specifically, the MDS assessments for two residents, who were admitted and later expired in the facility, were completed and signed by an LPN instead of the RN MDS Coordinator. The facility's policy mandates that the RN MDS Coordinator is responsible for certifying the completion of resident assessments, which was not adhered to in these cases. During interviews, the LPN responsible for completing the MDS assessments acknowledged that the assessments for the two residents were not signed by the RN Coordinator, as they should have been. The RN MDS Coordinator, who was not in the role at the time of these assessments, confirmed that all MDS assessments must be signed by an RN. The previous RN MDS Coordinator was responsible for signing off on the RN Attestation for all MDS assessments, but this was not done for the assessments in question.
Failure to Ensure RN Certification of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set 3.0 (MDS) assessments were certified as complete by a Registered Nurse (RN) for 13 residents. Instead, a Licensed Practical Nurse (LPN) signed off on these assessments, which is against the facility's policy that requires an RN to verify the completion of MDS assessments. This practice was identified during interviews, clinical record reviews, and document reviews, highlighting a significant deviation from the required protocol. The report details that the LPN signed the MDS assessments under Section Z - Assessment Administration, which is designated for the RN Assessment Coordinator's signature. This occurred for various types of MDS assessments, including Quarterly, Annual, and Admission assessments, for residents with a range of medical conditions such as edema, nutritional deficiency, multiple sclerosis, glaucoma, and dementia, among others. The LPN confirmed having signed these assessments over several months, acknowledging that an RN should have been responsible for verifying the assessments. The Chief Nursing Officer (CNO) confirmed that the LPN had signed all MDS assessments as the RN Assessment Coordinator for a specific period. The CNO acknowledged that while the LPN could collect data for individual assessments, the RN was required to sign off to ensure accuracy and completeness. The facility's policy, effective since 2015, clearly states that the RN/MDS Coordinator is responsible for completing all sections of the MDS and for the final submission, which was not adhered to in this case.
Failure to Transmit Discharge MDS Timely
Penalty
Summary
The facility failed to ensure the timely transmission of the Discharge Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) for one resident, identified as Resident 87. This deficiency was identified during a review of Resident 87's records, which showed that the resident was originally admitted on January 30, 2024, and readmitted on July 14, 2024, with diagnoses including metabolic encephalopathy, heart failure, diabetes mellitus, and hyperlipidemia. The resident was discharged to an Assisted Living Facility on August 30, 2024, but the discharge MDS was not completed or transmitted within the required 30-day period. During an interview, the Minimum Data Set Nurse (MDSN) admitted to forgetting to complete the discharge MDS for Resident 87. The Director of Nursing (DON) emphasized the importance of completing and submitting all MDS assessments on time to ensure accurate reporting to CMS. The facility's failure to complete and transmit the discharge MDS in a timely manner had the potential to affect the quality-of-care monitoring system, which is crucial for ensuring safe and efficient resident-centered care.
Falsification and Removal of Clinical Records in LTC Facility
Penalty
Summary
The facility failed to meet professional standards and practices by falsifying documentation and removing clinical records for two residents. For the first resident, who had a severely impaired cognitive status and required significant assistance with daily activities, a urine sample was obtained without a physician's order. This was done by restraining the resident to insert a catheter, which resulted in bruising. The Licensed Practical Nurse (LPN) on duty documented the incident thoroughly, but her notes and related reports were removed from the resident's clinical record. The Director of Nursing (DON) denied any recollection of the event and claimed there were no injuries, despite evidence provided by the LPN. In the second case, a resident with severe cognitive impairment was pulled from a chair by another resident, resulting in a fall and a bruise. A Certified Nurse Aide (CNA) witnessed the incident and reported it to other staff members. However, the incident was documented as a fall by a Licensed Practical Nurse (LPN), who later denied being instructed to alter the documentation. The DON was informed of the incident but allegedly instructed staff to document it as a fall to avoid police involvement. Both incidents highlight significant deficiencies in the facility's handling of resident care and documentation. The removal and alteration of records, as well as the failure to accurately report incidents, demonstrate a lack of adherence to professional standards and practices. These actions compromised the integrity of resident care and the facility's accountability in managing resident incidents.
Inaccurate MDS Coding for Resident with Wounds
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) for a resident, identified as R26, who was reviewed for wounds. R26 was admitted in September 2023 with medical conditions including an abscess on the buttocks, a non-pressure chronic ulcer with fat layer exposed, protein-calorie malnutrition, and end-stage renal disease. Despite these conditions, the MDS completed on 9/21/24 did not mention the non-pressure skin ulcer, although it noted the application of a nonsurgical dressing. Subsequent medical records, including a history and physical on 9/29/23 and a wound care progress note on 10/09/24, confirmed the presence of a left buttock abscess and a skin ulcer with fat layer exposed, respectively. Interviews conducted with the resident and staff revealed discrepancies in the MDS coding process. The resident was aware of daily wound dressing changes but was unsure why the wound had not healed over nine months. A registered nurse confirmed the presence of a non-pressure ulcer and acknowledged that the wound was previously coded under surgical wounds in the MDS. The Director of Nursing was unaware of the MDS coding process, and the MDS Coordinator's job description emphasized the need for accurate assessments and compliance with regulations. The facility's MDS 3.0 Completion policy required accurate assessment and identification of care needs, which was not adhered to in this case.
Failure to Ensure Accurate Resident Assessment Dates
Penalty
Summary
The facility failed to ensure that resident assessments were not backdated for three of the 13 sampled residents. For Resident #23, the Quarterly Assessment was dated with an Assessment Reference Date (ARD) of 08/25/24, but the Director of Nursing (DON) signed the assessment as completed on 09/08/24, while sections A-E, GG, and H-Q were completed on 10/03/24. Similarly, Resident #37's Quarterly Assessment had an ARD of 09/05/24, with the DON signing completion on 09/19/24, and sections completed on 10/22/24. For Resident #45, the Quarterly Assessment had an ARD of 08/29/24, with the DON signing completion on 09/12/24, and sections completed on 10/03/24. During an interview on 10/24/24, the DON and MDS #1 were questioned about how assessments were signed before sections were completed. MDS #1 stated that data collection and resident interviews were conducted timely, but data input was delayed. The DON admitted to changing the date on the MDS to reflect when the assessment data and interviews were completed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.