Inaccurate MDS Assessment of Oral/Dental Status
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident out of four reviewed. A resident admitted with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety was documented in quarterly MDS assessments as having no oral or dental issues. However, observation revealed the resident was without natural upper teeth, and the resident reported losing several teeth since admission and not being offered assistance to see a dentist. Interviews with the MDS RN and an LPN confirmed uncertainty and inaccuracy regarding the resident's dental status, and the Director of Nursing acknowledged the MDS assessment did not accurately reflect the resident's oral or dental condition.
Penalty
Resources
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A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
Surveyors found that two residents had inaccurate MDS assessments. One resident with dementia and a history of falls had an MDS indicating no falls since the prior assessment, despite nursing documentation of a fall during that period, which the DON confirmed should have been captured. Another resident with Alzheimer's disease and chronic kidney disease had an MDS indicating they were receiving dialysis, although the clinical record contained no dialysis documentation and the DON confirmed the resident was not on dialysis. These issues were cited under CFR 483.20(g) for accuracy of assessments.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
A resident with type 2 DM and hyperglycemia had a physician order for daily Lantus insulin injections, which were administered and documented on the MAR. However, the quarterly MDS completed by the MDS Coordinator did not reflect that the resident received insulin injections or hypoglycemic medication. In interviews, the MDS Coordinator acknowledged overlooking and incorrectly coding these medications, and both the corporate MDS coordinator and the DON confirmed that the resident had been receiving daily insulin and that the MDS should have accurately captured relevant medications.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
Facility staff failed to accurately complete an admission MDS when a resident was incorrectly coded as receiving an anticoagulant with a documented indication, despite no corresponding physician order, care plan entry, or physician progress note confirming anticoagulant use. The same MDS also recorded a BIMS score indicating intact cognition, but the primary deficiency involved the inaccurate documentation of high-risk drug class use.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Inaccurate MDS Assessments for Falls and Dialysis Status
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments for two residents, contrary to regulatory requirements that assessments accurately reflect a resident's status and be properly certified. One resident with dementia and a history of falls had an MDS assessment dated February 2, 2026, that indicated there had been no falls since the prior assessment dated November 3, 2025. However, a nurse's note documented that this resident experienced a fall on November 24, 2025. In an interview, the DON confirmed that this MDS assessment was inaccurate and should have captured the fall that occurred in November. For the second resident, who had diagnoses including Alzheimer's disease and chronic kidney disease, the MDS assessment dated February 10, 2026, indicated that the resident was receiving dialysis while in the facility. Review of the clinical record revealed no documentation that the resident was receiving dialysis at that time. In an interview, the DON confirmed that this MDS entry was inaccurate and that the resident was not on dialysis. The survey cites these inaccuracies under CFR 483.20(g) Accuracy of Assessments, which had been previously cited on 4/16/25.
Plan Of Correction
Lead RNAC will pull list of residents who have had any falls in last quarter and ensure falls are listed on the MDS. RNAC secretary will check list of residents with MDSs due and weekly and will check each name to see if any of the residents had a fall and will communicate that to the RNAC/LNAC. RNACs/LNACs will audit the nursing sections of two MDSs done by another team member weekly x 4 weeks, then two MDSs biweekly x 1 months, two monthly. Two monthly will continue as a routine quality indicator. Schedule will be adjusted based on results. (I.e. increase if errors are found or continue with two monthly as routine quality indicator if no errors are found.) Lead RNAC will report results of audits to QAPI.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Inaccurate MDS Coding for Insulin and Hypoglycemic Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of medications. The resident was admitted with type 2 diabetes mellitus with hyperglycemia and had a physician order dated 02/16/26 for Lantus Solostar U-100 insulin, 10 units subcutaneously each morning for diabetes. Review of the February 2026 Medication Administration Record (MAR) showed the resident received daily insulin injections as ordered. However, the resident’s quarterly MDS dated 02/20/26 did not indicate that insulin injections or hypoglycemic medications had been received. During interviews, the MDS Coordinator confirmed she completed the 02/20/26 MDS for this resident, acknowledged that the resident received insulin daily, and stated that the MDS should have included both insulin injections and the use of hypoglycemic medication but these were overlooked and coded incorrectly. The Corporate MDS Coordinator stated that all MDS assessments should be coded correctly for relevant medications. The Director of Nursing also confirmed that the resident had received daily insulin injections and that the MDS should be coded correctly for relevant medications.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for Resident #39. The resident was admitted with diagnoses including liver cirrhosis, diabetes, and status post right foot trans metatarsal amputation. The admission MDS with an assessment reference date of 4/6/2026 documented that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15/15, indicating intact cognitive abilities for daily decision-making. In section N0415 (High-Risk Drug Classes: Use and Indication), the MDS coded that the resident was receiving an anticoagulant and that an indication for its use was documented. However, review of the Physician’s Order Summary, the resident’s care plan, and a physician progress note dated 4/7/2026 did not show any order, documentation, or care plan entry indicating that the resident was actually receiving an anticoagulant. During an interview, the MDS Coordinator acknowledged that the 4/6/2026 admission MDS was not coded accurately because the resident had not been taking an anticoagulant.
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