Unqualified Staff Certifying MDS Assessments
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments were certified by qualified staff, as required. The Administrator discovered that an LPN had certified an MDS assessment as the RN MDS Coordinator when she printed an MDS for a resident. Subsequent review revealed that this same LPN had signed and certified a total of 64 MDS assessments as the RN MDS Coordinator over two separate periods of employment, despite not being qualified to do so. These improperly certified assessments involved 40 residents and occurred between July 2022 and December 2025. The Administrator’s audit of approximately 1,500 MDS assessments showed that the LPN participated in the MDS assessment process for 351 residents and, without an identifiable pattern or rationale, signed as the RN MDS Coordinator on 64 of those assessments. The Administrator stated there was always an RN MDS Coordinator or the DON available to review and certify assessments during the relevant time frames, and she did not know why the LPN certified them. The previous RN MDS Coordinator was no longer employed, so the Administrator could not verify what process that RN had followed to ensure proper review and certification of MDS assessments. Review of records for selected residents confirmed that the original MDS assessments in question had been certified by the LPN as the RN MDS Coordinator.
Penalty
Resources
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The facility failed to accurately complete MDS assessments for three residents. One resident with a history of stroke and other comorbidities had a documented fall during a transfer attempt, but the subsequent MDS indicated no falls since the prior assessment. Another resident with Alzheimer’s disease and other conditions had multiple documented falls, including one with a head injury and another with a skin tear, yet the quarterly MDS recorded no falls and omitted the major injury. A third resident with an indwelling Foley catheter and orders for daily catheter care and urine output monitoring was coded on the MDS as always incontinent of urine, even though nursing staff confirmed the resident was always continent due to the catheter.
The facility failed to accurately code MDS assessments for several residents receiving respiratory services. Three residents with chronic respiratory conditions and orders for AVAPS, a non-invasive ventilation mode aligned with BiPAP, were incorrectly coded on the MDS as receiving invasive mechanical ventilation, despite observations showing no invasive ventilator use and RAI guidance limiting that code to closed-system ventilation via endotracheal tube or tracheostomy. Another resident with a history of acute respiratory failure, COPD, and other comorbidities was documented in progress notes and by an LPN and the DON as receiving continuous oxygen via nasal cannula, yet had no physician order for oxygen, no care plan addressing oxygen therapy, and an MDS that indicated no oxygen use, contrary to facility policy requiring accurate, comprehensive resident assessments.
Surveyors found that MDS assessments were inaccurately coded for two residents. For one resident with dementia and mood and anxiety disorders, bed handrails ordered and used for mobility were coded on the MDS as a daily physical restraint, despite no restraint assessment or care plan documentation and observation showing the rails did not restrict movement. For another resident with Wernicke’s encephalopathy, psychotic disorder with hallucinations, and dementia, documentation showed the pneumococcal vaccine was offered and declined, but the MDS recorded that the resident was not up to date because the vaccine had not been offered. Facility nursing leadership and the MDS nurse confirmed both MDS assessments were coded inaccurately.
MDS assessments were inaccurately coded for multiple residents. Several residents with documented level II PASRR determinations for serious mental illness were marked “No” on the MDS question about state level II PASRR status, and another resident’s MDS incorrectly showed no scheduled pain meds despite active routine orders for oxycodone ER and Lyrica during the look-back period.
Inaccurate MDS coding of hearing status. A resident with multiple chronic conditions had MDS and hearing assessments that documented hearing as adequate and no hearing devices, despite audiology records showing bilateral hearing aids/amplifiers. Observation and staff interviews confirmed the resident needed assistance placing and managing the hearing aids, and staff verified the devices were not coded on the MDS.
Incorrect MDS Coding for Ventilator Therapy and Medications The facility failed to code several resident assessments accurately in the MDS. Multiple residents using AVAP/AVAPS therapy by facial mask were coded as receiving invasive mechanical ventilation, even though the RT, RTM, MDS nurse, and DON confirmed the devices were non-invasive and no resident had an ET tube or trach. Two additional residents were miscoded for medication items, with one receiving an anticoagulant and another receiving a diuretic despite the MDS showing otherwise.
Inaccurate MDS Coding for Falls and Urinary Continence
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments were accurately completed for three residents. For one resident with a history of cerebral infarction, diabetes, hypertension, heart failure, and need for personal assistance, the fall risk assessment documented a fall in the previous three months, and a fall investigation showed he fell while attempting to transfer from his wheelchair to his bed without staff assistance, with no injury noted. However, the subsequent quarterly MDS assessment documented that he had no falls since admission or the prior MDS, despite the documented fall. The Administrator confirmed that the MDS section J was incorrect because the fall without injury should have been recorded. Another resident with Alzheimer’s disease, chronic kidney disease, and hypertension had multiple documented falls over a three‑month period, including falls resulting in a skin tear and a head injury, as well as two falls without injury. Despite these documented events and an admission MDS completed earlier, the quarterly MDS assessment recorded that the resident had no falls since admission or the prior MDS, and an LPN confirmed that this was inaccurate and that one fall with a head injury should have been coded as a major injury. A third resident with multiple diagnoses, including bullous pemphigoid, morbid obesity, asthma, anxiety, depression, heart disease, hypertension, and neuromuscular bladder dysfunction, had a physician’s order for an indwelling urinary catheter with daily catheter care and daily monitoring of urinary output. The annual comprehensive MDS assessment documented that this resident had an indwelling Foley catheter but was always incontinent of urine, whereas an RN confirmed that the resident was always continent of urine due to the Foley catheter, indicating inaccurate coding in the bowel and bladder section.
Inaccurate MDS Coding for Ventilator and Oxygen Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for multiple residents, particularly in the coding of respiratory services and oxygen therapy. For three residents with diagnoses including chronic obstructive pulmonary disease, obstructive sleep apnea, and dependence on a respirator/ventilator, quarterly or annual MDS assessments were coded to indicate use of an invasive mechanical ventilator. Physician orders for these residents specified use of average volume-assured pressure support (AVAPS), described as ventilator/volume targeted pressure support with detailed settings and daily use requirements. However, observations of these residents during the survey showed them in wheelchairs or in their rooms without invasive mechanical ventilation in place. Further clarification from the state RAI/OASIS Education Coordinator and reference to NIH StatPearls identified AVAPS as a form of non-invasive ventilation most closely aligned with BiPAP, which should be coded as BiPAP on the MDS rather than as invasive mechanical ventilation. The RAI manual instructions for coding invasive mechanical ventilation specify that it applies to residents receiving closed-system ventilation via endotracheal tube or tracheostomy, or those being weaned from such devices, and explicitly state not to code this item when the ventilator is used only as a substitute for BiPAP or CPAP. Despite this, the MDS nurse confirmed that the three residents’ MDS assessments were coded as receiving invasive mechanical ventilation, stating that he believed the MDS manual directed him to do so. The facility also failed to accurately assess and document oxygen therapy for another resident with diagnoses including acute respiratory failure with hypoxia, COPD, heart failure, hypertension, type 2 diabetes, and generalized anxiety disorder. This resident’s quarterly MDS indicated that oxygen therapy was not required, and multiple care plans over several months did not include oxygen therapy. Physician orders during the review period contained no order for oxygen administration. In contrast, progress notes on multiple dates documented that the resident was receiving oxygen via nasal cannula, and an LPN confirmed the resident was on 2 L/min oxygen without a corresponding physician order, believing it to be as-needed and longstanding. The DON verified that the resident had been receiving oxygen therapy for an extended period without a physician order, that oxygen was not included in the care plan, and that the MDS assessment was inaccurate regarding oxygen use, contrary to the facility’s policy requiring comprehensive assessments and attestation to MDS accuracy.
Inaccurate MDS Coding for Restraint Use and Pneumococcal Immunization
Penalty
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.
MDS Assessments Were Inaccurately Coded for PASRR Status and Pain Medication Use
Penalty
Summary
The facility failed to accurately code resident MDS assessments. Review of 24 residents identified nine residents whose MDS assessments did not match the medical record and PASRR documentation. For Residents #29, #32, #52, #53, #62, #64, #87, and #102, the records showed level II PASRR determinations for serious mental illness, but the most recent comprehensive MDS assessments answered “No” to the question asking whether the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #29 had diagnoses including schizophrenia, dementia, and major depressive disorder, and a level II PASRR evaluation dated 03/21/07 showed serious mental illness. Resident #32 had diagnoses including delusional disorder, hallucinations, and major depressive disorder, with a level II PASRR evaluation dated 06/16/23 showing serious mental illness. Resident #52 had diagnoses including heart failure, schizophrenia, and generalized anxiety disorder, with a level II PASRR evaluation dated 08/21/21 showing serious mental illness. Resident #53 had diagnoses including hypoxemia, schizophrenia, and acute respiratory failure, with a level II PASRR evaluation dated 12/01/15 showing serious mental illness. Resident #62 had diagnoses including mood disorder, intermittent explosive disorder, and bipolar disorder, with a level II PASRR evaluation dated 11/14/24 showing serious mental illness. Resident #64 had similar diagnoses and a level II PASARR evaluation dated 12/02/25 showing serious mental illness. Resident #87 had diagnoses including mood disorder, schizophrenia, and schizoaffective disorder, and a level II PASRR evaluation from the prior facility dated 12/04/24 showed serious mental illness. Resident #102 had diagnoses including cocaine dependence, schizophrenia, and schizoaffective disorder, and a level II PASRR evaluation from the prior facility dated 08/07/24 showed serious mental illness. In addition, Resident #11’s MDS assessment was incorrect regarding pain medication use: the resident was cognitively intact and the MDS indicated no scheduled pain medication, but physician orders showed active routine orders for oxycodone ER 10 mg twice daily and Lyrica 75 mg three times daily, and MDS Nurse #609 verified the resident was on routine pain medication during the five-day look-back period.
Inaccurate MDS Coding of Hearing Status
Penalty
Summary
The facility failed to accurately assess and document a resident’s hearing status on the MDS. Resident #1 was admitted with diagnoses including pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The MDS assessments, including quarterly and annual assessments, documented that the resident’s hearing was adequate and that she did not use hearing devices, and the care plan contained no interventions related to hearing devices. The hearing, speech, and vision assessment also reflected no hearing devices. Record review and observations showed the resident used hearing aids in both ears. Audiology consultations dated 05/16/23 and 08/16/23 documented that she utilized hearing aids and/or amplifiers in both ears, and one consultation noted she was working with the audiologist because the hearing aids were echoing. During observation on 02/25/26, the resident was visibly upset and struggling to place both hearing aids into her ears and stated no one had helped her. Staff interviews confirmed she required assistance with hearing aids, that staff were responsible for helping her with them and keeping them charged, and that the hearing aid devices were not coded on the MDS assessments.
Incorrect MDS Coding for Ventilator Therapy and Medications
Penalty
Summary
The facility failed to ensure resident assessments were accurate and coded correctly in the MDS database for six residents reviewed. The deficiency involved incorrect MDS coding for mechanical ventilation and medication items, including residents who were documented as receiving non-invasive AVAP/AVAPS therapy through a facial mask but were coded as using invasive mechanical ventilation. Facility staff, including the MDS nurse, DON, RT, RTM, and corporate nurse, confirmed that the AVAP/AVAPS machines used by residents were non-invasive and that none of the residents had endotracheal tubes or tracheostomy tubes. For one resident with congestive heart failure, COPD, obesity, depression, diabetes, and anxiety, the record showed physician orders for mechanical ventilator via AVAP at bedtime and as needed, care plans focused on ventilator dependence, and observation showed the resident in bed on nasal cannula without using the ventilator at the time. The resident stated he used a face mask at night and had never had an endotracheal or tracheostomy tube. The Administrator and MDS nurse stated they had been instructed by corporate to code the resident as using invasive mechanical ventilation based on the MDS interpretation of the AVAP device, despite staff confirming the device was non-invasive. Similar findings were identified for other residents receiving AVAP/AVAPS therapy. One resident with COPD, sleep apnea, myocardial infarction, heart disease, and hypertension was coded as using invasive mechanical ventilation even though the resident reported using the face mask only at night and sometimes refusing the device, and RT staff confirmed the therapy was non-invasive. Another resident with dementia, dependence on respirator status, central sleep apnea, and chronic respiratory failure was observed asleep in bed with the AVAPS machine off, while staff confirmed the device was used via face mask and was non-invasive. In addition, two residents had MDS assessments that incorrectly documented medication use: one resident was coded as not receiving an anticoagulant despite daily Rivaroxaban administration, and another resident was coded as not receiving a diuretic despite daily Hydrochlorothiazide administration. The DON confirmed both MDS assessments were incorrectly coded.
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