Falsification and Removal of Clinical Records in LTC Facility
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 severe cognitive impairment and required significant assistance with daily activities, an incident occurred where staff obtained a urine sample without a physician's order. This involved restraining the resident, which led to bruising. A Licensed Practical Nurse (LPN) documented the event thoroughly, but her notes and related incident reports were removed from the resident's clinical record. The Director of Nursing (DON) denied any recollection of the event and claimed no records were removed, 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 bruising. A Certified Nurse Aide (CNA) witnessed the incident and reported it to a Licensed Practical Nurse (LPN) and a Certified Med Aide (CMA). The LPN documented the incident as a fall, omitting the physical altercation, and later denied being instructed to alter the documentation. The DON was informed of the incident, but the report was inaccurately recorded, potentially to avoid police involvement. Both incidents highlight significant deficiencies in the facility's documentation practices and adherence to professional standards. The removal and alteration of records, as well as the failure to accurately report incidents, demonstrate a lack of integrity in maintaining accurate clinical records and ensuring resident safety. These actions compromise the quality of care and violate regulatory requirements for accurate resident assessments and documentation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
The facility failed to ensure accurate MDS assessments when two residents were incorrectly coded as having daily physical restraints in section P0100, despite observations showing no restraints in their beds or wheelchairs. One resident with epilepsy and dementia was seen in a wheelchair without restraints, while another resident with diabetes and an above-the-knee amputation was observed in bed using only a trapeze bar for repositioning. The DON and MDS coordinator later acknowledged that the restraint coding on both MDS assessments was incorrect.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
The facility failed to ensure accurate completion of MDS assessments for two residents, leading to incorrect coding of antidepressant use and falls. For one resident with Alzheimer’s disease and major depressive disorder, the quarterly MDS indicated antidepressant use during the lookback period despite no active physician order or eMAR documentation of antidepressant administration. For another resident with dementia, the quarterly MDS coded one fall with no injury since the prior assessment, although the clinical record contained no fall documentation and the Administrator confirmed no fall occurred. The Regional Clinical Nurse reported that the MDS Coordinator had reviewed the wrong dates when coding these sections.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Inaccurate MDS Coding of Physical Restraints for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ actual status, resulting in incorrect documentation of physical restraints for two residents. One resident with epilepsy and dementia, observed in a wheelchair on 4/12/26 with no restraints in the wheelchair or bed, had a quarterly MDS that coded in section P0100 “Physical Restraints, Other used daily” for restraint use. Another resident with diabetes and an above-the-knee left leg amputation, observed in bed with a trapeze bar used to assist with repositioning and with no restraints in the bed or wheelchair, had an admission MDS that also coded in section P0100 “Physical Restraints, Other used daily” for restraint use. On 4/13/26, the DON and MDS coordinator stated that these MDS assessments were coded incorrectly and confirmed that neither resident had restraints, indicating that the inaccurate coding stemmed from staff error in completing the MDS.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
Inaccurate MDS Coding for Medication Use and Falls
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect coding of antidepressant use and falls. For one resident with diagnoses including Alzheimer’s disease and major depressive disorder, the quarterly MDS dated 3/30/26 indicated the resident received an antidepressant during the 7‑day lookback period, but the clinical record contained no active physician order for an antidepressant and the electronic Medication Administration Record showed no administration of an antidepressant during that time. For another resident with dementia, the quarterly MDS dated 3/30/26 coded one fall with no injury since the prior assessment on 12/29/25, yet the clinical record contained no documentation of a fall during that interval, and the Administrator confirmed the resident did not fall in that period. During interviews, the Regional Clinical Nurse stated that both MDS assessments dated 3/30/26 for these residents were wrong because the MDS Coordinator looked at the wrong dates for the fall and antidepressant, while the Administrator stated that the facility followed Resident Assessment Instrument (RAI) guidelines to code MDS assessments.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
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