Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. One resident, who had a tracheostomy tube placed prior to admission and was observed with a speaking valve, was not identified as having a tracheostomy on her MDS assessment with an assessment reference date of 05/22/25, despite medical records confirming the presence of the tracheostomy at admission. The Director of Nursing later confirmed the inaccuracy of this MDS assessment. Another resident's admission assessment indicated a history of a fall within the last 31-180 days prior to admission, but the corresponding MDS section J1700 B inaccurately documented that the resident had not fallen in the previous two to six months. The Nursing Home Administrator confirmed this MDS was also inaccurate.