Inaccurate Coding of MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessment data for two of twelve sampled residents. For one resident, the annual assessment dated 03/23/25 had both the functional assessment and pain section marked as not assessed, despite the resident being on routine pain management. The Director of Nursing (DON) confirmed that the assessment was incomplete and not accurate, noting that the corporate nurse had completed the assessment but could have delegated the unassessed areas to a facility nurse. For another resident, the quarterly MDS assessment dated 03/18/25 did not indicate that the resident was on hospice services, even though a physician order dated 06/30/24 documented the resident's admission to hospice. The DON confirmed that the resident had been on hospice since 06/30/24 and that the MDS assessment should have reflected this status.