The facility failed to ensure accurate MDS coding of current tobacco use for multiple cognitively intact residents who were active smokers. Several residents with conditions such as COPD, pulmonary fibrosis, heart failure, schizophrenia, paraplegia, hypertensive heart disease, epilepsy, and depression were repeatedly observed smoking in the designated smoking room. Each had a signed smoking agreement, a smoking assessment identifying them as smokers, and a care plan addressing smoking in a designated area, yet their admission, annual, or significant-change MDS assessments did not reflect current tobacco use in Section J1300. The MDS Manager reported that Section J1300 is completed by the MDS department using resident assessments, staff interviews, medical record review, and a periodically updated smoking list from recreation, but was not aware of these specific discrepancies.
A resident with multiple complex medical conditions, including cellulitis, bacteremia, and numerous documented wounds (e.g., Stage III sacral ulcer, deep tissue injuries to hips and heels, unstageable hip wound, gangrenous toes, and a left bunion wound), was admitted and readmitted with detailed hospital records and facility admission notes describing these skin issues. Despite this, MDS assessments in two separate assessment periods documented no skin problems or only moisture-associated skin damage, omitting the full-thickness wounds, pressure injuries, and gangrene. The MDS coordinator and MDS director reported relying on the wound nurse’s documentation and the medical record without physically assessing the resident or reconciling discrepancies between hospital discharge information and internal wound assessments, resulting in inaccurate MDS coding of the resident’s skin condition.
A resident with dementia, seizure disorder, and COPD had a care plan indicating dependence for bed mobility with a need for total assistance from two staff, but the MDS assessment was inaccurately coded as requiring only partial/moderate assistance. Observation showed two staff providing total assistance for bed mobility, and interviews with an RN, a CNA, and the rehab director all confirmed the resident required total care with two-person assistance for bed mobility and transfers. The rehab department completed the MDS bed mobility section, and the rehab director later acknowledged the coding error, while the MDS coordinator stated they were unaware of the discrepancy despite their usual process of using assessments, staff interviews, and record review for MDS completion.
The facility failed to ensure accurate and complete MDS assessments for multiple residents when cognitive sections, including the BIMS and Section C, were coded as "not assessed" or left incomplete without evidence that interviews could not be performed. Record review showed several quarterly, annual, and admission assessments missing required cognitive data, even when documentation indicated the resident should have been interviewed. A regional social worker reported that interviews not completed within the look-back period were coded as not assessed, while the DON and Administrator stated they were unaware of the incomplete sections and that these issues were not identified through the QAPI process.
A resident with gastrostomy, esophageal cancer, and dysphagia had a PEG tube and received tube feeding during the assessment period, but the admission MDS did not indicate the feeding tube in Section K. The Dietician said the omission was an error, the MDS nurse said signing Section Z only verified completion, and the DON stated the assessment should have accurately reflected the resident’s feeding tube status.
A resident’s MDS did not accurately code tobacco use even though the care plan identified the resident as a known smoker, a nursing smoking assessment documented smoking, and a smoking contract was signed. The resident stated they smoked cigarettes three times a day in the smoking room, and the MDS Coordinator acknowledged that tobacco use should have been coded on the assessment.
Two residents’ MDS assessments were inaccurately coded by an LPN, resulting in failure to reflect actual falls and pressure ulcer status. One resident with orthopedic and oncologic conditions had two documented falls, yet their quarterly and annual MDS assessments indicated no falls during the relevant look-back periods. Another resident with cancer, hypertension, and anemia developed a facility-acquired stage 3 pressure ulcer to the left ischium, but the subsequent quarterly MDS incorrectly coded the ulcer as present on admission, despite documentation and the LPN’s acknowledgment that it was not present on admission.
A resident with COPD, vasculitis, and cellulitis had a sacral pressure injury that was initially documented by an admission nurse as a stage 2 ulcer, while a wound care provider shortly thereafter assessed it as unstageable with necrosis and the care plan identified it as stage 4. Because the wound care provider’s assessments were uploaded into the record after the MDS ARD 7‑day look‑back period, the staff member completing the MDS only saw the earlier stage 2 assessment and coded the wound accordingly, resulting in inaccurate MDS coding of the resident’s pressure injury status.
A resident with hemiplegia, major depressive disorder, and type 2 DM did not receive a timely admission Comprehensive MDS assessment within the required 14-day timeframe. The MDS coordinator allowed the ARD from a prior admission to remain active because the earlier assessment cycle and comprehensive care plan had not been fully closed by all disciplines, and the new stay was incorrectly treated as a readmission without verifying admission status. As a result, the current admission’s comprehensive MDS was not initiated and completed as required and remained overdue, while the administrator reported being unaware of any MDS tracking or ARD issues and had not been informed of the delay.
Surveyors found that MDS assessments did not accurately reflect the status of two residents. One resident with multiple comorbidities had repeated refusals of medications, IV therapy, and care, along with documented aggressive/combative behavior and behavior symptoms in nursing notes, MARs, and CNA ADL records, yet the MDS indicated no refusals or behaviors. Another resident with a chronic scalp infection and osteomyelitis had physician orders and documented treatments for a right temporal wound, but both the 5-day and quarterly MDS assessments recorded no ulcers, wounds, or skin problems. The Regional MDS Coordinator reported that errors occurred due to new staff completing MDS sections and a vacancy in the MDS Coordinator role, with corporate staff attempting to keep up with assessments.
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 June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account