Inaccurate MDS Coding for Hearing, Oxygen Use, and Functional Status
Summary
The deficiency involves inaccurate completion of the Minimum Data Set (MDS) for two residents, resulting in assessments that did not reflect their actual hearing status, oxygen (O2) use, and functional abilities. For one resident with metabolic encephalopathy, influenza A, acute respiratory failure with hypoxia, and acute pulmonary edema, surveyors observed that he repeatedly responded "huh" during attempted interviews and interactions, indicating difficulty hearing. Despite this, his MDS documented no difficulty in normal conversation or social interaction, no hearing aid in use, and an ability to understand others. The MDS also indicated receipt of speech-language pathology and audiology services, while physician orders and notes contained no documentation of hearing aids, audiology assessments, or hearing services, and physician notes described his speech as clear and that he was able to understand and be understood. An LPN stated the resident was hard of hearing and did not have hearing aids at the facility, and the DON later acknowledged she was unaware of any hearing issues and that the MDS hearing section was not accurate. The same resident’s MDS was also inaccurate regarding O2 use. Physician progress notes over January documented fluctuating O2 saturations, continued O2 supplementation, and use of O2 via nasal cannula at 2 LPM, with later notes indicating the resident was on room air. Nursing notes during this period alternately documented no O2 in use, room air, and O2 via nasal cannula. A physician order dated early February called for a room air trial to determine ongoing O2 need, and on observation the resident was seen on room air with an oxygen concentrator at the bedside that was off and without tubing attached. Despite this history of O2 use and changes, the resident’s MDS contained no documentation regarding O2 use. The DON stated it was her expectation that O2 use be documented in the MDS and confirmed the MDS was not accurate regarding O2 use. For a second resident with Parkinson’s disease, dysphagia, and scoliosis, nursing progress notes over several months documented that she was bedbound and dependent on all activities of daily living, with multiple entries describing her as bedbound and at baseline in that status. However, two MDS assessments during this period coded Section GG (Functional Abilities) to indicate that a wheelchair (manual or electric) was the mobility device normally used in the last seven days. Observations by surveyors found the resident to be bedbound, and the DON stated that the resident’s functional decline from wheelchair use to being bedbound should have been considered a change in condition, but she could not determine when the change occurred. The DON further stated that documentation showed the resident had been bedbound since 2023, that she did not recall the resident using a wheelchair, and that the MDS assessments were documented incorrectly because the resident could not use a wheelchair and required bedbound care. A significant change MDS was not completed despite this documented functional decline.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
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.
A resident with diabetes had quarterly MDS assessments that incorrectly coded insulin use despite current orders showing weekly semaglutide injections and no insulin orders. The resident stated she did not receive insulin, and an RN confirmed the MDS was coded incorrectly and needed modification. The DON stated the MDS should accurately reflect each resident’s status.
A resident’s quarterly MDS failed to code use of a non-invasive ventilatory device, even though a BiPAP machine was observed at bedside and the resident stated staff assisted with it at night. The chart also included orders for CPAP/BiPAP use for OSA, and the MDS coordinator confirmed the assessment was coded incorrectly.
A facility failed to accurately code MDS assessments for code alert device use for multiple residents identified as at risk for elopement and wandering. Although a wander guard log showed several residents had code alert devices, the MDS often stated the devices were not in use and did not reflect wandering behavior. Several care plans also lacked elopement or wandering interventions, and staff interviews confirmed the MDS should reflect code alert placement because it drives the care plan.
Inaccurate MDS coding affected two residents. One resident’s PASARR Level II status was coded inconsistently with the record, and another resident’s MDS failed to code an antidepressant on Item N0415 even though the resident was receiving Trazodone for insomnia and had diagnoses including schizoaffective disorder, major depressive disorder, and anxiety.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
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 Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately code medication on the Minimum Data Set (MDS) assessment for 1 resident who was reported to be receiving insulin. The resident had a diagnosis of diabetes, and the quarterly MDS assessments accepted on 2/3/26 and 4/15/26 identified that the resident received an insulin injection 1 time during the last 7 days. However, the resident’s current physician orders showed no insulin orders. Instead, the orders included semaglutide, with instructions for a weekly subcutaneous injection on Wednesdays for diabetes with hyperglycemia, beginning at 0.25 mg and then increasing to 0.5 mg. During interview, the resident stated she did not receive insulin and instead received a weekly GLP-1 injection on Wednesdays. The RN confirmed she had incorrectly coded both quarterly MDS assessments as the resident receiving no insulin and stated she would need to complete and submit a modification of the assessment. The DON stated she would expect the MDS to be accurate and reflect each resident’s status.
MDS Incorrectly Omitted BiPAP Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident who used a non-invasive ventilatory device. The resident’s quarterly MDS dated [DATE] identified intact cognition with no hallucinations or delusions, but in Section O, the item for non-invasive mechanical ventilator use, including BiPAP and CPAP, was not checked, and Section Z1, “none of the above,” was marked instead. During observation, a BiPAP machine was seen on the resident’s bedside table with a gallon of water next to it, and the resident stated staff assisted with the machine at night. The resident later stated she had previously used CPAP and had been changed to BiPAP. The medical record included an order to resume CPAP with home settings and an after-visit summary documenting BiPAP home use with specified pressure settings for obstructive sleep apnea. An LPN stated staff assisted the resident with a CPAP machine, and the MDS coordinator confirmed the quarterly MDS was coded incorrectly because the resident did use a non-invasive ventilatory device.
Inaccurate MDS Coding for Code Alert Devices
Penalty
Summary
The facility failed to ensure accurate MDS coding for the use of code alert devices for 14 of 14 residents identified as at risk for elopement and wandering. The code alert system log titled Wander Guard Monitor for 4/2026 identified residents R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46 as having a code alert device in use, but their MDS assessments did not consistently reflect that information in Section P. Instead, the assessments frequently indicated that a wander guard alarm was not in use and that the residents had not exhibited wandering behavior. Several resident records also lacked corresponding care plan interventions for elopement and wandering. R3, R4, R18, R22, R28, R32, R34, R37, and R46 had care plans that did not include elopement or wandering interventions, and R22's care plan did not identify the placement location of the code alert device. R37's problem area for elopement was not initiated until 5/1/26. R46 was discharged on 4/20/26, and the care plan was requested but not received. R19's most recent elopement assessment identified low risk and included clothing labeled with identification and an identification band, but did not select the door alarm band applied as an intervention. R12's assessments similarly identified low risk and listed clothing labeling and an identification band, but did not select the door alarm band applied. The record also showed inconsistencies between assessments, documentation, and staff statements. R13 and R17 had elopement assessments completed on 5/1/26 and their code alert devices were removed, while R19's EMR lacked evidence that elopement assessments were completed quarterly. R12's EMR lacked evidence of quarterly elopement assessments, and progress notes stated the assessments were reviewed with no change despite later documentation of a successful exit of the building and attempts to exit. During interviews, staff stated that residents with wandering or elopement risks should be identified on the care plan, that code alert devices were kept in a book at the main entrance desk, and that the MDS should be coded to reflect code alert placement because it drives care and the care plan.
Inaccurate MDS Coding for PASARR Status and Antidepressant Use
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessment for 2 of 24 residents reviewed for MDS accuracy. For Resident 64, the clinical record showed diagnoses including anxiety and bipolar disorder, and a PASARR dated 5/8/23 indicated a Level II screening. However, the annual MDS assessment dated 1/30/26 stated the resident was not currently considered by the State to have a Level II PASARR screening, which was inconsistent with the PASARR information in the record. For Resident 9, the clinical record included diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. A physician order dated 6/26/25 showed Trazodone HCl 25 mg by mouth at bedtime for insomnia, but the quarterly MDS assessment dated 2/18/26 did not indicate the resident received an antidepressant medication on Item N0415. The RAI Manual stated medications are to be coded in Item N0415 according to therapeutic category and/or pharmacological classification, and the MDS Coordinator acknowledged the resident was taking an antidepressant at the time of the assessment and that Item N0415C1 should have been coded yes.
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.
Trusted by long-term care providers and associations.
