Inaccurate MDS Assessment for Resident
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 25 sampled residents. Clinical record review showed that the resident had diagnoses of anxiety, depression, and atrial fibrillation. However, the MDS assessment incorrectly indicated that the resident had a tracheostomy, despite no supporting physician's orders or care plan documentation in the clinical record. During an interview, the Administrator confirmed that the MDS was inaccurate and that the resident did not have a tracheostomy. This deficiency was identified through clinical record review and staff interview, which revealed a discrepancy between the resident's documented medical conditions and the information recorded on the MDS assessment.