Inaccurate MDS Coding for Restraint Use and Pneumococcal Immunization
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments related to restraint use and immunization status. For one resident with dementia, mood disorder, and anxiety disorder, the medical record showed a physician’s order for bilateral handrails to promote bed mobility due to weakness, with checks every shift. The MDS assessment section P for this resident coded bed rails as a physical restraint used daily. However, the care plan did not document any restraint use, and the medical record did not contain a restraint assessment. Observation showed the bed had two small handrails at the top on each side, used for bed mobility, which did not inhibit the resident’s movement in or out of bed or otherwise restrain the resident. Facility staff, including the ADON and MDS nurse, confirmed the handrails were ordered for mobility and were not assessed as restraining the resident, indicating the MDS coding was inaccurate. For another resident with Wernicke’s encephalopathy, psychotic disorder with hallucinations, and dementia, the vaccine consent form documented that the resident was offered and declined the pneumonia vaccine. Despite this, the MDS assessment indicated the resident was not up to date with the pneumonia vaccine because it had not been offered. During interview, the ADON and MDS nurse confirmed that the pneumonia vaccine had been offered and declined, and that the MDS assessment had been coded inaccurately. These findings show that the facility failed to ensure MDS assessments accurately reflected the residents’ status regarding both restraint use and immunization history, as required by the accuracy of assessments regulation.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #11 on 03/26/2026. It was determined that there were no negative effects related to the lack of "Side Rail Assessment"/Grab Bar Evaluation. DON completed an assessment for the need and use of bilateral handrails to promote bed mobility due to weakness on 03/26/2026. It was determined that the bedrail is being used for promoting bed mobility not being used in a way that prevents or restrains Resident #11 from normal daily functioning. LNHA notified Resident #11's primary care provider on 03/26/2026, of findings noted during Annual Survey and that no negative effects were identified during assessment/observation related to the lack of "Side Rail Assessment"/Grab Bar Evaluation documentation. MDS Nurse corrected Resident #11's MDS on 03/20/2026 to reflect that his bed rails were no longer being used. On or before 4/30/2026, DON/Designee will ensure that other residents residing in the facility and using bedrails have a "Side Rail Assessment"/Grab Bar Evaluation completed to verify that bedrails are being utilized to promote mobility and in no way prevent/restrain a person from from normal daily function(ing). Assessment/evaluation by nursing/therapy will establish the use of which side or bilateral grab bars for mobility purposes. All residents will have care plan in place reflecting the accurate use of grab bar for mobility purposes. DON completed a head-to-toe physical assessment/observation on Resident #20 on 03/26/2026. It was determined that there were no negative effects related to the lack of documentation or related to the documentation discrepancy regarding the Pneumococcal vaccination (nursing documentation reflects that the vaccine was refused, but the MDS documentation describes that it was not offered) identified during Annual Survey. LNHA notified Resident #20's primary care provider on 03/36/2026, of findings noted during Annual Survey and that no negative effects were identified during assessment/observation related to the documentation discrepancy regarding the Pneumococcal vaccination (nursing documentation reflects that the vaccine was refused, but the MDS documentation describes that it was not offered). Primary care provider acknowledged the documentation discrepancy pertaining to the Pneumococcal vaccination. No new orders were provided. On or before 4/30/2026, DON/Designee will review the medical records of like residents residing in the facility to ensure that consents and care plan documentation aligns and that Pneumococcal vaccinations are administered per orders. On or before 04/30/2026, DON/Designee will provide education to licensed nursing personnel (including MDS nursing staff) regarding the following: 483.20(g)(h)(i)(j) Accuracy of F 0641 Assessments §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. §483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. §483.20(i) Certification. §483.20(i)(1) A registered nurse must sign and certify that the assessment is §483.20(i) (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. §483.20(j) Penalty for Falsification. §483.20(j) (1) Under Medicare and Medicaid, an individual who willfully and knowingly- (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. Also, on or before 04/30/2026, DON/Designee will provide education to licensed nursing personnel (including MDS nursing staff) explaining that: DON/MDS/Designee will review nursing documentation when completing MDS assessments to ensure that accurate coding is reflected in the MDS coding, specifically when a resident is using grab bars as a mobility device (not a restraint) and/or Pneumococcal vaccinations are offered/provided/declined. Discrepancies should be addressed with the Director of Nursing prior to coding by the MDS coordinator. On or before 04/30/2026, DON/Designee will compile a list of like residents who have bed rails. On or before 04/30/2026, DON/Designee will review the compiled list of like residents who have bed rails and ensure there is a current and accurate "Side Rail Assessment" documented. On or before 04/30/2026, DON/Designee will ensure that care plans and physician orders accurately reflect the use of bedrails and results from the "Side Rail Assessment." On or before 04/30/2026, DON/Designee will review MDS assessment for residents using bedrails to ensure accurate data has been coded and reported regarding the use and reasoning of use of bedrails. On or before 04/30/2026, DON/Designee will compile a list of residents, and their Pneumococcal vaccination status is. On or before 04/30/2026, DON/Designee will complete a complete audit to ensure that Pneumococcal vaccination statuses are accurately reflected in the medical record (i.e. consents, care plans). On or before 04/30/2026, DON/Designee will perform a complete audit to review most recent MDS assessment to ensure that MDS assessment accurately reflects the resident's Pneumococcal vaccination status. QAA. This audit will list the resident identifier (facility identifier), if they utilize bedrails, date of their last "Side Rail Assessment" why they utilize bed rails, and ensure accurate documentation is reflected in physician orders, care plan, and the recent MDS assessment. QAA. This audit will list resident identifier (facility identifier), the status of their Pneumococcal vaccination (offered, administered, declined, etc.), and ensure that this information is accurately reflected in the care plan and recent MDS assessment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure MDS assessments accurately reflected resident status for several residents. One resident’s admission MDS listed insulin injections even though she received liraglutide, while two other residents’ MDSs omitted antidepressant, opioid, and scheduled pain medication use despite active orders and MAR documentation. Another resident’s quarterly MDS failed to include respiratory failure as an active dx even though the record, orders, and resident interview confirmed the condition and oxygen use.
Inaccurate resident assessments were identified for multiple residents when MDS coding did not match the clinical record, observations, or staff statements. One resident was coded as having a restraint-related chair device despite no restraints being observed or ordered, another was coded as not receiving antibiotics despite MAR documentation of mupirocin use, and two other residents had missing or incorrect MDS entries for diagnoses, ROM status, and skin/wound conditions based on admission records, physician notes, wound care documentation, and staff interviews.
Inaccurate MDS coding affected two residents. One resident had significant weight loss documented in the EHR, but the quarterly MDS did not reflect the loss as required. Another resident with lung cancer and metastatic disease had an admission MDS that omitted active cancer diagnoses from section I. The MDS/LPN acknowledged the missing diagnosis, and the DON stated MDS assessments were expected to be coded accurately.
A facility failed to ensure MDS assessments accurately reflected resident status for multiple residents. One resident’s oxygen use was not captured in Section O despite PRN O2 orders and repeated oxygen saturation documentation, another resident’s MDS omitted oxygen use despite progress notes and an O2 order, a third resident’s MDS omitted depression despite a citalopram order, and a fourth resident’s MDS coded no ROM impairment even though PT identified quadriplegia with limitations in all extremities.
A resident’s quarterly MDS incorrectly coded significant weight loss even though his documented weights did not show 5% loss in 1 month or 10% loss in 6 months. The MDS RN said she based the coding on weight fluctuations and medication changes rather than actual loss during the look-back period, and the resident’s care plan continued to reflect significant unplanned weight loss, poor intake, and anxiety.
Inaccurate MDS coding was found for two residents whose diabetes meds were non-insulin injectables. One resident with ESRD and diabetes had Ozempic ordered, and another resident with CKD and diabetes had Mounjaro ordered, but both MDS assessments incorrectly coded insulin use and hypoglycemic drug class use. The MDS coordinator acknowledged the coding error but did not update the assessments after learning of the inaccuracy.
Inaccurate MDS Assessments for Medication Use and Diagnoses
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for 4 of 24 residents reviewed. For Resident #54, the admission MDS documented 2 insulin injections in the prior 7 days and identified diabetes mellitus, but the medication record showed she was receiving liraglutide subcutaneously once daily and was not prescribed insulin. The MDS nurse stated liraglutide is a diabetic medication but is not insulin, and the admission MDS should not have noted insulin injections. For Resident #57, the quarterly MDS did not document antidepressant use in Section N or scheduled pain medication in Section J. The resident’s orders included trazodone 150 mg daily, Tylenol 325 mg two tablets twice daily for pain, and Voltaren gel twice daily for left knee pain, and the MAR showed these medications were administered during the lookback periods. The care plan also identified a need for antidepressant medication and noted a potential for uncontrolled pain. For Resident #81, the quarterly MDS did not list respiratory failure as an active diagnosis even though the resident’s record included acute and chronic respiratory failure with hypoxia and an active order for acetazolamide for respiratory failure. The resident was observed with oxygen equipment in his room and stated he used oxygen at night because of his respiratory failure. For Resident #91, the MDS did not document opioid use in Section N or scheduled pain medication in Section J, despite an active order for tramadol 50 mg twice daily for chronic pain and MAR documentation showing it was administered during the lookback period. The MDS nurse stated she was responsible for ensuring MDS accuracy and that inaccurate information could mean care was not delivered correctly or something could be missed.
Inaccurate Resident Assessments
Penalty
Summary
Resident assessments were not completed accurately to reflect resident status for 4 of 9 residents reviewed. For one resident, the quarterly MDS dated 5/8/2026 indicated under Section P that a chair prevented rising and was used less than daily, yet observations on 6/8/2026 and 6/9/2026 showed the resident sitting in a wheelchair with no restraints observed, and the resident stated she did not use any restraints. The physician orders also did not document any restraint use, and staff, including the LPN, MDS Coordinator, and DON, stated that no restraints were used in the facility. For another resident, the quarterly MDS dated 5/23/2026 marked Section N Medications as no antibiotics, but the physician order and MAR showed Mupirocin External Ointment 2% was administered from 5/16/2026 through 5/22/2026 for a fungal rash on the left pointer and middle fingers. The MDS Coordinator stated that the assessment should have reflected antibiotic use and said it would be corrected. The DON stated the facility follows the RAI. For a third resident, the admission record listed a left humerus fracture, ventral hernia, and schizophrenia, but the MDS dated [DATE] coded Section GG as no impairment of upper or lower extremity, omitted schizophrenia from Section I, and marked Section M skin conditions as none. Observation showed the resident wearing a black sling on the left arm, and the resident stated she had a hernia surgery in 2010 and had been dealing with the surgical site since then. The wound care nurse described a large weeping abdominal hernia being treated with dressings, and the MDS Coordinator acknowledged the coding was incorrect. For a fourth resident, the admission record and physician documentation showed a history of TIA and cerebral infarction without residual, but the MDS Section I did not include those diagnoses. The MDS Coordinator stated the resident had a TIA and stroke history and that it needed to be added to Section I.
Inaccurate MDS Coding for Weight Loss and Active Diagnoses
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) accurately reflected the status of 2 of 22 sampled residents reviewed for assessment accuracy. For Resident 112, the electronic health record showed admission with diagnoses including diabetes, weakness, and hemiplegia/hemiparesis affecting the right side. The resident was able to make needs known. The record also showed weights of 184 pounds on 03/14/2026, 150 pounds on 04/11/2026, and 146 pounds on 04/19/2026, but the 05/06/2026 quarterly MDS marked the item for loss of 5 percent or more in the last month or loss of 10 percent or more in the last 6 months as NO or UNKNOWN. For Resident 21, the electronic health record showed admission with diagnoses including malignant neoplasm of the lung and secondary malignant neoplasm of the brain and adrenal gland. The admission MDS showed the resident was able to communicate needs, but the cancer diagnoses were not coded in section I for active diagnoses. During interviews, the MDS/LPN stated the cancer diagnosis was missing from the MDS and should have been coded, and the DON stated the expectation was that MDS assessments were coded accurately and that active diagnoses should be on the MDS.
Inaccurate MDS Assessments for Oxygen Use, Depression, and Range of Motion
Penalty
Summary
The facility failed to ensure resident assessments were completed accurately to reflect resident status for 4 of 13 residents reviewed. Resident #3’s Medicare 5-day MDS dated 5/7/2026 did not document oxygen use in Section O, even though the physician order dated 4/28/2026 directed oxygen 2L via nasal cannula PRN and the resident’s oxygen saturation records showed repeated oxygen use during the look-back period. The MDS Coordinator stated the assessment needed to be corrected because the resident did use oxygen during the look-back period. Resident #15’s Medicare 5-day MDS dated 4/2/2026 also did not document oxygen use in Section O, despite a physician order for O2 at 3L via nasal cannula PRN for respiratory distress and progress notes documenting oxygen use via nasal cannula at 2L and 3L. Resident #56’s modification of admission Medicare 5-day MDS dated 4/9/2026 did not document depression in Section I, although the resident had an order for citalopram 20 mg daily related to depression. Resident #19’s MDS dated 4/15/2026 coded no impairment in range of motion for both upper and lower extremities in Section GG, while the resident was observed in PT receiving services and was identified by the PT as a quadriplegic with spinal cord injury and limitations in range of motion in all extremities.
Inaccurate MDS Weight Loss Coding
Penalty
Summary
The facility failed to ensure Resident #7’s assessment accurately reflected his status when the quarterly MDS completed on 03/23/26 coded Section K0300 as significant weight loss in the last month or last 6 months. Resident #7 was a 63-year-old male admitted with diagnoses including unspecified protein-calorie malnutrition and dehydration, and his BIMS score was 9, indicating moderately impaired cognition. The MDS also supported a care plan focus area for significant unplanned/unexpected weight loss, poor food intake, and anxiety issues that had been initiated on 10/16/25. Record review of Resident #7’s weights showed no 5% weight loss in 1 month or 10% weight loss in 6 months relative to the ARD date of the quarterly MDS. His documented weights were 119 pounds on 03/22/26, 117.2 pounds on 02/20/26, and 120 pounds on 09/24/25. During interview, the MDS RN stated she coded significant weight loss because the resident’s weight had fluctuated and medication changes seemed to have affected his weight, rather than because of actual weight loss during the look-back period. The facility policy stated the purpose of the MDS is to ensure each resident receives an accurate assessment, and the RAI manual stated that only the two snapshot weights closest to 30 and 180 days are considered for K0300.
Inaccurate MDS Coding for Diabetes Medications
Penalty
Summary
The facility failed to ensure accurate MDS coding for dialysis-related medications for two residents. Resident 4 had diagnoses including type 2 diabetes mellitus without complications, end stage renal disease, and dependence on renal dialysis. His EMR showed an order for Ozempic (semaglutide) 0.25 mg subcutaneously once weekly for diabetes, but his annual MDS coded section N0350 as insulin injections in the last seven days as yes and section N0415J hypoglycemic (including insulin) as yes. Resident 59 had diagnoses of chronic kidney disease and type 2 diabetes mellitus without complications. Her EMR showed an order for Mounjaro (tirzepatide) 2.5 mg subcutaneously once weekly for diabetes, but her quarterly MDS coded section N0350 as one insulin injection in the last seven days and section N0415J hypoglycemic (including insulin) as yes. The MDS coordinator stated she knew Ozempic and Mounjaro were coded inaccurately as insulin and learned of the inaccuracy on 4/24/26, but did not update the MDS assessments for residents 4 and 59.
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