Inaccurate MDS Coding for Side Rail Use: A resident with Alzheimer's disease and cognitive communication deficit had a quarterly MDS that incorrectly coded daily side rail use and restraint use. Observations showed the resident in bed without side rails or restraints, and both an LPN and the MDSC confirmed the resident had never used bedside rails or any physical restraints. The Administrator also acknowledged the MDS was inaccurate.
MDS Incorrectly Coded Discontinued Antipsychotic Medication: A resident with Alzheimer's disease and dementia with behavioral disturbance had quetiapine discontinued, but the annual MDS still indicated antipsychotic use. The MDS Coordinator confirmed the med was outside the 7-day look-back period and should not have been coded, while the care plan and MAR reflected the discontinuation.
Inaccurate MDS coding for significant weight loss. A resident with encephalopathy, pneumonia, severe sepsis with septic shock, and oropharyngeal cancer had a significant unplanned weight decline, but the quarterly MDS coded weight loss as a physician-prescribed weight-loss regimen. Dietary notes documented trending weight loss and variable intake, and the MDS Coordinator said the coding was based on diuretic use even though the medication had been prescribed long before. The DHS confirmed the coding was inaccurate and that no care plan revisions had been made to address the weight trend.
A resident with protein calorie malnutrition and a terminal prognosis was admitted on hospice with corresponding physician orders and a care plan, but hospice services were not coded on either the admission or quarterly MDS assessments. The MDS Coordinator and two MDS LPNs confirmed that, despite the resident receiving hospice care, Section O of both MDS assessments incorrectly indicated the resident was not on hospice, which the Administrator and DON acknowledged resulted in inaccurate MDS data.
An inaccurate MDS assessment failed to code a resident’s ordered CPAP use in Section O, even though the resident had diagnoses including OSA, COPD, asthma, and acute respiratory failure with hypercapnia. The resident was observed on supplemental O2 and reported using O2 daily and attempting to wear CPAP at night; the RN Case Mix Director and Administrator confirmed the respiratory treatments had not been coded on the MDS.
Surveyors found that MDS assessments were not accurately completed for two residents. One resident with multiple medical conditions, including epilepsy and vascular dementia, had a quarterly MDS that documented no falls, even though facility incident records and staff interviews confirmed an unwitnessed fall that led to hospital transfer. Another resident with peripheral vascular disease had an MDS indicating daily bed rail use, while observations over several days, the resident’s own statements, the care plan, and physician orders all showed that no bed rails were present or ordered. The MDS Coordinator and unit leadership acknowledged that the MDS coding for both residents was incorrect.
A resident with a stroke history, right-sided hemiplegia, and aphasia had multiple MDS assessments that coded no upper extremity impairment despite OT orders and staff confirmation of a right-hand contracture. During observation, the resident stated he could not open his right hand, and the MDSC acknowledged the assessments were inaccurate.
Inaccurate MDS coding for elopement risk was identified for two residents. Both had severe cognitive impairment on BIMS, care plans that identified wandering or exit-seeking behavior and wander guard use, and observations confirmed wander guard bracelets in place, yet Section P of the quarterly MDS assessments coded alarms as not used and the physician's orders did not include orders for the wander guards. MDS Coordinators confirmed the coding errors.
A resident with multiple psychiatric and cardiac diagnoses had an annual MDS completed with Section E (behavioral symptoms) coded as showing no behaviors, despite EMR documentation of hostility, disorientation, incontinence, paranoid statements, and unsafe smoking behavior involving staff intervention. The MDS Coordinator later acknowledged that the documented behaviors should have been coded on the MDS, and leadership stated that accurate behavior coding would have triggered a new care plan, while also noting the facility relies on the RAI Manual rather than a specific internal MDS policy.
A resident admitted with multiple diagnoses, including septic knee infection and pressure ulcers, had IV antibiotic orders and a PICC line placement order, but the admission MDS documented a midline catheter instead of the ordered PICC. The resident arrived without IV access, the on-call MD was notified, and an IV company later inserted the line, while the MDS coordinator said she assumed the resident had a midline because the prior company only placed midlines. During observation, the resident had IV access with an undated dressing, and the DON stated assessments and PICC or midline dressings were expected to be accurate and dated.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.