Inaccurate MDS Assessment Related to Resident Fall
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 accurately complete a Minimum Data Set (MDS) assessment for one resident. According to the MDS 3.0 RAI Manual, falls since the last assessment must be documented. A review of the medical record showed that the resident, who had diagnoses including dementia, diabetes, and hypothyroidism, was found on the floor on 4/14/2025. The resident's quarterly MDS assessment, however, did not reflect this fall, despite documentation in the nurse's note and the care plan indicating the incident. The MDS Coordinator confirmed that the assessment was inaccurate during an interview.