F0641

D

Inaccurate MDS Coding of Resident Functional Status and Mobility Needs

Fairmont, West Virginia Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to ensure an accurate MDS assessment reflecting a resident’s physical status. Record review for Resident #38 showed an ADL care plan indicating the resident required dependent assistance of two staff for bed mobility; setup and substantial/maximal assist of one for toileting; substantial/maximal assist of one for dressing; partial/moderate to dependent assist of one for personal hygiene; and substantial/maximal assist of one for bathing. The resident’s diagnoses included dependence on a wheelchair, difficulty in walking, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side. Despite these documented functional limitations and care needs, the MDS with an ARD of 11/11/25 was coded in Section GG0115 as having 0 upper and lower extremity limitations in range of motion, and Section GG0120 as using no mobility devices. In an interview, the DON confirmed that the MDS coding was incorrect based on the resident’s physical status.

This failed practice was identified as a random opportunity for discovery and was determined to have the potential to affect a limited number of residents during the complaint survey, with a facility census of 108 and the deficiency specifically involving Resident #38.