Inaccurate MDS Assessments for Treatments and Medications
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the current clinical status and treatments for three sampled residents. For one resident who began receiving oxygen therapy on September 25, 2025, the MDS assessment dated [DATE] documented in Section O that the resident had not received oxygen therapy in the preceding seven days, despite clinical records confirming ongoing oxygen use; the DON later confirmed this MDS was inaccurate. For another resident with hepatic failure and asthma, the MDS dated [DATE] indicated the resident was receiving an anticoagulant medication, but review of the clinical record revealed no physician orders for any anticoagulant. Similarly, for a resident with cerebrovascular disease and bipolar disorder, the MDS dated [DATE] also indicated receipt of an anticoagulant medication, yet the clinical record contained no corresponding physician orders. These discrepancies between the MDS assessments and the clinical records demonstrate that the assessments did not accurately capture the residents’ actual treatments and medication regimens.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.