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F0641
D

Inaccurate and Incomplete MDS Assessments Identified

Greensboro, North Carolina Survey Completed on 09-13-2025

Penalty

No penalty information released
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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 accurately complete Minimum Data Set (MDS) assessments for three residents in several key areas. For one resident with acute respiratory failure, non-Alzheimer's dementia, and who was bedbound and on hospice, the MDS inaccurately coded the resident as only occasionally incontinent of bladder and frequently incontinent of bowel, when in fact the resident was always incontinent of both. This was confirmed by the MDS nurse during an interview, who acknowledged the coding was incorrect. Another resident with chronic kidney disease and respiratory failure was incorrectly documented as having received an antibiotic during the 7-day look back period on the MDS, despite medication administration records showing no antibiotics were given during that time. Additionally, a third resident with multiple diagnoses, including gout, diabetes with polyneuropathy, and hemiplegia, had an annual MDS assessment that was incomplete, with cognitive and pain assessments marked as "not assessed, no information." Staff interviews confirmed these inaccuracies and omissions in the MDS assessments.

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