Inaccurate and Incomplete Quarterly MDS Assessment for ADL Status
Summary
The deficiency involves the facility’s failure to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment accurately reflected her functional status and care needs. The quarterly MDS, completed by an LVN, did not properly address the resident’s Safety and Quality of Performance in multiple Activities of Daily Living (ADLs), including eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene, and did not indicate the type of wheelchair or scooter used. The resident was an elderly female with a BIMS score of 03, indicating severe cognitive impairment, and her physician orders included the use of geri sleeves to both upper extremities every shift. Her quarterly care plan documented an ADL self-care performance deficit, risk for not having needs met in a timely manner, and risk for emotional distress, and specified that she required assist of one person for personal hygiene and bathing, along with scheduled and as-needed grooming and hygiene care and encouragement to use the call light for assistance with ADLs. Interviews with facility leadership confirmed that the incomplete and inaccurate MDS had not been identified or corrected. The ADON stated she was not aware that the resident’s MDS did not address her functional abilities and contained incomplete sections, and acknowledged that timely completion of the MDS was important because it reflected the resident’s daily care and needs to maintain the highest level of care. The DON stated it was her expectation that MDS staff conduct timely, comprehensive quarterly assessments to address the resident’s current status of care and prevent decline, and that it was the responsibility of the DON and MDS staff to ensure MDS assessments were completed comprehensively. The facility’s Clinical Practice Guidelines for MDS Completion required residents to be assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan, with quarterly assessments completed within the required timeframe, but this process was not followed for the resident’s quarterly MDS.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with CKD stage 5 and ESRD had an MDS that did not indicate dialysis in Section O, even though the resident had active orders for dialysis, a care plan for dialysis-related needs, and staff confirmed he was receiving dialysis at an outside clinic on a regular schedule. The MDS nurse stated dialysis should have been triggered on the assessment and described the omission as an oversight/data entry error.
A facility failed to accurately code oxygen use in the MDS for 3 residents reviewed for respiratory services. Each resident had physician orders for oxygen and vitals documentation showing oxygen via NC or mask, but the Quarterly MDS assessments did not record oxygen use in Section O. The MDS Coordinator stated the assessments needed to be modified because the charting showed oxygen use, and the DON stated the facility follows the RAI.
MDS assessments were inaccurately coded for falls and PASRR for multiple residents. One resident’s MDS did not fully reflect two documented falls, including one with a major injury, and several residents with documented Level II PASRR determinations were coded as not currently considered by the state PASRR process to have SMI/ID or a related condition. Staff interviews confirmed the chart contained the PASRR information, but the MDS entries did not match the record.
Inaccurate MDS Coding for Bedrail Use. The facility failed to accurately code the MDS for two residents reviewed for bedrail use. Both residents were cognitively intact and had diagnoses including cardiac conditions and high blood pressure, and both MDS assessments stated they did not use bedrails. However, surveyors observed quarter bed rails on both sides of each bed, and the medical records did not indicate bedrail use. The DON stated the MDS must be accurate because it drives the resident plan of care and reimbursement.
MDS assessment did not accurately capture a resident’s ongoing behaviors during ADL care. The resident had dementia, anxiety, depression, and diabetes with neuropathy, and staff and family described repeated episodes of screaming, cursing, hitting, scratching, resisting care, and attempting to bite during personal care and transfers. CNA notes and the MAR did not clearly document the behaviors, the care plan did not address them, and the MDS nurse said she did not interview nursing staff or review CNA documentation when completing the assessment.
A resident with a hx of cerebral infarction, HTN, and generalized muscle weakness had an inaccurate MDS mobility assessment. The MDS documented use of a walker and wheelchair, while rehab, RNA, IDT notes, and staff interviews showed the resident ambulated with a single point cane and was highly functioning. The DON and ADON stated the MDS was not accurate, and the MDSN confirmed the cane use was not reflected.
MDS Did Not Reflect Resident’s Dialysis Treatments
Penalty
Summary
The facility failed to ensure Resident #17’s MDS assessment accurately reflected that the resident was receiving dialysis treatments. Resident #17 was a [AGE]-year-old male admitted with diagnoses including diabetes, hyperlipidemia, peripheral vascular disease, and chronic kidney disease stage 5. The most recent MDS assessment reflected kidney disease and moderate cognitive impairment for daily decision-making, but Section O did not indicate that the resident required dialysis. Record review showed the resident had active orders for dialysis-related care, including checking the left upper arm shunt every shift for signs and symptoms of infection or bleeding and receiving dialysis at a clinic on Monday, Wednesday, and Friday. The comprehensive care plan also identified that the resident required dialysis treatments related to end stage renal disease. During interviews, staff stated the resident had been receiving dialysis before admission and continued while in the facility. The MDS nurse reviewed the assessment and stated dialysis should have been triggered on the MDS and that it was an oversight and data entry error.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to provide an accurate assessment for 3 of 7 residents reviewed for respiratory services. For Resident #22, the physician ordered continuous oxygen at 3 L via nasal cannula or face mask, and the resident’s weights and vitals summary documented repeated oxygen saturation readings with oxygen via nasal cannula, but the Quarterly MDS dated 6/13/2026 did not document oxygen use in Section O Special Treatments, Procedures, and Programs. During interview, the MDS Coordinator stated the assessment needed to be modified because the resident had a continuous oxygen order and oxygen saturation documentation using oxygen via nasal cannula. For Resident #44, the physician ordered oxygen at 2 L via nasal cannula to keep oxygen saturation greater than 90%, with instructions to contact the provider if saturation dropped below 90% as needed for hypoxemia/SOB. The resident’s weights and vitals summary documented multiple oxygen saturation readings with oxygen via nasal cannula and one reading with oxygen via mask, but the Quarterly MDS dated 4/15/2026 did not document oxygen use. For Resident #109, the physician ordered oxygen at 2 L via nasal cannula PRN for hypoxemia, and the weights and vitals summary documented oxygen saturation readings with oxygen via nasal cannula, but the Quarterly MDS dated 5/21/2026 also did not document oxygen use. The MDS Coordinator stated both residents’ assessments should be modified because the documentation showed oxygen use, and the DON stated the facility follows the RAI.
MDS Assessments Incorrectly Coded for Falls and PASRR
Penalty
Summary
The facility failed to accurately code MDS assessments in the areas of falls and PASRR for 7 of 22 residents reviewed for MDS accuracy. The record review and staff interviews showed that several MDS assessments completed by a traveling MDS Coordinator did not match information documented in the residents’ medical records, including fall events and Level II PASRR determinations. For one resident admitted with chronic respiratory failure with hypoxia and a healing left humerus fracture, the admission MDS coded a fall in the last month and a fracture related to a fall prior to admission. However, nurse progress notes documented two separate falls after admission: one in which the resident rolled out of bed and landed on her buttocks, and another in which the resident was found on the floor next to the bed with right hip pain and was sent to the ER. Hospital records showed an acute comminuted impacted right intertrochanteric fracture, and the discharge MDS coded only one fall with major injury. The MDS Coordinator later stated the resident had two falls since the prior assessment and that the discharge MDS should have reflected one fall with no injury and one fall with major injury. For six residents, the MDS assessments did not accurately reflect existing Level II PASRR determinations. The records showed Level II PASRR notification letters for residents with diagnoses including anxiety disorder, bipolar disorder, unspecified dementia with psychotic disturbances, schizoaffective disorder, major depressive disorder, and other psychiatric conditions. The annual, significant change, or admission MDS assessments for these residents stated they were not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, despite documentation in the chart showing active PASRR determinations. Staff interviews confirmed the PASRR letters were in the EMR and that the MDS Coordinator was responsible for coding PASRR, but the assessments were still coded without the Level II PASRR information.
Inaccurate MDS Coding for Bedrail Use
Penalty
Summary
Ensure each resident receives an accurate assessment. The facility failed to accurately code the Minimum Data Set (MDS) for 2 of 6 residents reviewed for bedrails. One resident’s comprehensive MDS indicated the resident was cognitively intact with diagnoses including atrial fibrillation, high blood pressure, and arthritis, and Section P stated the resident did not use bedrails; however, during observation and interview, quarter bed rails were present on both sides of the bed, and the resident stated they had been there since admission. Another resident’s quarterly MDS indicated the resident was cognitively intact with diagnoses including coronary artery disease, heart failure, and high blood pressure, and Section P also stated the resident did not use bedrails; however, during observation and interview, quarter bed rails were noted on both sides of the bed, and the resident stated they were not used for positioning. In both cases, the medical record did not indicate the use of bedrails. The DON stated the MDS should be accurately completed with all necessary information because it drives the resident plan of care and reimbursement.
MDS Assessment Did Not Reflect Resident Behaviors
Penalty
Summary
The facility failed to ensure one resident’s Annual MDS assessment accurately reflected the resident’s behaviors during daily care. The resident had a history of major depression, anxiety disorder, diabetes mellitus with neuropathy, and was also documented with non-Alzheimer’s dementia, anxiety disorder, adjustment disorder with anxiety, and depression. The Annual MDS recorded unclear speech, a BIMs score of 03, and no behavioral symptoms, with overall presence of behavioral symptoms marked as none. Record review showed the CNA documentation for June 2026 included 16 episodes of behaviors on several evening shifts, but the entries did not specify the behaviors exhibited when daily care was provided. The Nurses Medication Administration Record did not contain documentation of the resident’s behaviors reported by CNAs during personal care. The care plan also did not address the resident resisting care, screaming when touched, pushing and hitting staff during brief changes and repositioning, attempting to bite during transfers, or cursing and insulting staff during care. During interviews, the resident’s family member and multiple staff described the resident as screaming, cursing, hitting, scratching, resisting care, and attempting to bite when staff provided personal care or transferred her. A CNA stated the resident became anxious during care and would bite, hit, cuss, and scream, while an LVN said the resident had ongoing behaviors and resisted care. The MDS nurse stated she was not aware of the behaviors, did not interview nursing staff when completing the MDS, and did not review CNA documentation or the MAR for behaviors.
Inaccurate MDS Mobility Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when the 6/16/2026 MDS documented the resident as using a walker and a wheelchair, while other records showed the resident was ambulating with a single point cane. The resident was admitted on 3/10/2026 with diagnoses including cerebral infarction, essential HTN, and generalized muscle weakness, and the H&P dated 3/11/2026 stated the resident had the capacity to understand and make decisions. Record review showed the resident’s Rehabilitation-Screening Form dated 4/21/2026 indicated the resident was safe after PT screening to ambulate using a single point cane, and RNA orders were updated to include ambulation with a single point cane daily five times a week. A later Rehabilitation-Screening Form dated 6/5/2026 and IDT Conference Notes dated 6/16/2026 also indicated ambulation with a single point cane daily five times a week as tolerated. During interviews, RNA 1, the RD, the MDSN, the ADON, and the DON all acknowledged the resident used a single point cane and that the MDS assessment was not accurate.
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