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.
A resident with severe cognitive impairment and multiple diagnoses was documented in medical and dental assessments as having natural teeth with missing teeth and no dentures, while staff interviews revealed the resident actually had partial dentures. This inconsistency between staff knowledge and assessment documentation resulted in a deficiency related to inaccurate resident assessments.
A resident with diabetes and anxiety was documented in MDS assessments as having no dental issues, but was observed to be without natural upper teeth and reported losing teeth since admission without being offered dental assistance. Interviews with the MDS RN, an LPN, and the DON confirmed the inaccuracy of the resident's dental status in the MDS.
A resident was admitted with complex medical conditions and hospital records indicating buttock wounds, but the facility's admission assessment did not document these wounds. The MDS nurse, relying solely on hospital documentation and without conducting a personal assessment, recorded pressure injuries that were not present according to the facility's clinical evaluation. The discrepancy between hospital and facility findings was not addressed before completing the MDS assessment.
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.
Failure to Complete Accurate Dental Assessments
Penalty
Summary
The facility failed to ensure accurate assessments were completed for a resident with multiple diagnoses, including psychotic disorder with delusions, Parkinson's disease, anxiety, depression, dementia, and neurocognitive disorder with Lewy bodies. Medical record review showed that nursing admission and dental assessments consistently documented the resident as having natural teeth with missing teeth and no dentures. However, during staff interviews, a CNA reported that the resident had partial dentures, which was confirmed by the unit manager upon review of the assessments. The Minimum Data Set (MDS) assessment also indicated the resident had no broken or loosely fitting dentures and no mouth or facial pain, discomfort, or difficulty chewing. This discrepancy between staff knowledge and documented assessments led to the deficiency.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
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.
Inaccurate Admission MDS Skin Assessment Due to Unresolved Documentation Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of an admission Minimum Data Set (MDS) skin condition assessment for one resident. Upon review, the resident was admitted with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Hospital discharge documentation indicated the presence of a right buttock wound and a left buttock deep tissue injury. However, the facility's admission wound assessment, completed by the Director of Nursing (DON), documented only a surgical incision to the abdomen and a stage two pressure ulcer of the left axilla, with no mention of wounds to the buttocks. The admission MDS assessment, completed by an MDS Registered Nurse who had not personally assessed the resident, recorded a stage two pressure ulcer and a deep tissue injury based solely on hospital documentation. During interviews, the MDS nurse admitted uncertainty about how to proceed when hospital records and clinical assessments did not align, as she was still in training. Subsequent observation and interviews confirmed the absence of pressure ulcers or deep tissue injuries on the buttocks at admission. The facility's policy required interdisciplinary participation in resident assessments, but the discrepancy between hospital and facility findings was not resolved prior to completing the MDS assessment.
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