A resident’s quarterly MDS failed to include epilepsy in Section I Current Diagnoses even though the diagnosis was documented in the medical record. During review with the MDS RN, she acknowledged that epilepsy should have been marked and was missed.
A resident was observed smoking with staff present, but the Annual MDS incorrectly coded current tobacco use as 0, indicating the resident did not smoke. The CRC confirmed the MDS error during interview.
Accurate resident assessment was not maintained when two residents had incorrect MDS coding. One resident receiving hospice had an MDS that did not reflect hospice care and incorrectly answered the prognosis item, and another resident with an unstageable pressure ulcer present on readmission had an MDS that incorrectly showed zero ulcers present on admission or reentry. The MDS Coordinator and DON confirmed both assessments were inaccurate.
A resident receiving hospice services for end-of-life care related to cerebral infarction had a quarterly MDS that did not indicate hospice status, even though the physician order, care plan, and hospice communication book all showed hospice involvement. The MDS nurse confirmed the assessment was incorrect.
Incomplete and inaccurate MDS assessments were identified for two residents. One resident’s MDS incorrectly coded a wound infection, and another resident’s quarterly MDS incorrectly coded a hip fracture and other fracture, even though the medical record did not support those diagnoses during the look-back period. An LPN and the Administrator confirmed the coding errors were pulled from older MDS records.
Inaccurate discharge MDS assessment: A resident was discharged from the facility and was not expected to return, but the MDS stated that return was anticipated. A corporate nurse confirmed the resident did not return.
Inaccurate MDS for Toileting Schedule: A resident’s care plan included a toileting schedule upon rising, before and after meals, and at bedtime, but the significant change MDS marked “no” for both the urinary and bowel toileting programs. The MDS coordinator and DON confirmed the mismatch between the care plan and the MDS.
The facility failed to ensure the MDS accurately reflected the condition of two residents. One resident's MDS showed ambulation and omitted fractures, even though PT records and the PTA indicated the resident could not walk and had metatarsal fractures. Another resident's MDS listed walking 10 feet with supervision, but PT records and the PTA stated the resident had not walked in years; the Administrator confirmed the MDS was inaccurate.
A resident with schizoaffective disorder, bipolar type had Bipolar Disorder omitted from Section I on three MDS assessments. The medical record showed the diagnosis was active, but the MDSs did not mark it as an active diagnosis, and the NHA acknowledged the error.
A resident’s discharge return not anticipated MDS incorrectly coded the discharge destination as a short-term general hospital, even though a nursing note documented discharge home with home health. The DON later confirmed the resident was discharged home and that the MDS was coded incorrectly.
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 August 26, 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.