The MDS coordinator responsible for the assessments told inspectors she "needed MDS education" after acknowledging she had falsified completion dates on Medicare assessments for three residents. The administrator called the backdating "an unacceptable practice."
Federal inspectors found the facility failed to ensure accurate assessments for three of 21 residents reviewed, placing them at risk for unidentified care needs. The violations involved the Minimum Data Set, a federally required assessment tool that determines Medicare payments and care planning.
Staff T, the MDS coordinator, confirmed to inspectors that completion dates in medical records were backdated rather than reflecting actual completion dates. For Resident 67, the medical record showed a June 14 completion date, but assessment history revealed the coordinator actually finished it June 17. Resident 20's assessment was backdated from June 11 to June 7. Resident 45's assessment was completed April 9 but recorded as April 5.
The coordinator told inspectors she referred to federal RAI manual guidelines for assessment coding. She confirmed the backdated dates were "not the actual dates of completion."
Administrator Staff A stated during the inspection that she expected MDS coordinators to "attest and document the actual MDS completion date in the resident's medical records."
Beyond the backdating, inspectors found assessment coding errors that misrepresented residents' actual conditions.
Resident 28's May quarterly assessment failed to identify a psychosis diagnosis despite the resident receiving antipsychotic medication twice daily for delusions. The assessment showed no delusions during the assessment period, contradicting physician orders from May 2023 prescribing antipsychotic medication specifically "for delusions."
The resident's care plans documented a history of delusions dating to 2020, potential for violence due to paranoia and delusions from 2023, and ongoing antipsychotic medication use. Director of Nursing Staff B confirmed Resident 28 had a psychosis diagnosis that "should be reflected on the 05/20/2024 Quarterly MDS but was not."
For Resident 189, staff incorrectly coded a hospital return as a new admission rather than a reentry. The resident was hospitalized 12 days and returned to the facility, but staff marked the July entry tracking assessment as an admission instead of a reentry as required for hospitalizations under 30 days.
MDS coordinator Staff X explained to inspectors that accurate coding was important for "continuity and coordination of care for a resident" and stated "it is the Medicare rules." Staff T reviewed the assessment and admitted, "I did it wrong, it should be coded as a reentry."
The assessment errors extended to resident interviews about activity preferences. Resident 68's admission assessment marked all activity preference questions as "nonresponsive" despite the resident having intact memory and answering questions about mood, pain, and daily preferences during the same interview.
Staff completed a general assessment indicating Resident 68 was interested in keeping up with news, but left the outdoor activities section incomplete. When inspectors interviewed the resident, they expressed interest in getting outside but said they were "not offered the opportunity" and had "other interests besides just watching television in their room."
Staff T told inspectors Resident 68 was "sleepy and unresponsive during the resident activity preferences interview" and no second attempt was made. When asked why the resident could answer other interview questions but not activity preferences, Staff T responded, "that's a good question."
The coordinator acknowledged that using staff assessment instead of resident interviews provided "less detailed information" because it captured only general interest rather than the degree of interest in activities.
Federal regulations require nursing homes to conduct comprehensive assessments that accurately reflect each resident's physical, mental, and psychosocial functioning. The RAI manual warns that MDS signatories certify the information accurately reflects resident assessment data used for ensuring appropriate care and determining federal payments.
The manual states that payment of federal funds and continued participation in government healthcare programs depends on MDS accuracy and truthfulness. It warns signatories could face "substantial criminal, civil, and/or administrative penalties for submitting false information."
The inspection found the registered nurse responsible for attesting to assessment accuracy lacked adequate knowledge of MDS processes. Staff T confirmed she referred to the RAI manual for guidance but acknowledged needing additional education after the coding errors were identified.
The facility's assessment failures affected residents across multiple areas of care. Inaccurate mental health coding could impact medication management and behavioral interventions. Wrong entry classifications could affect Medicare coverage and care coordination. Incomplete activity assessments could limit recreational programming and quality of life interventions.
Resident 68 remains interested in outdoor activities that staff never offered, spending time watching television in their room instead.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marianwood Health and Rehabilitation from 2024-08-01 including all violations, facility responses, and corrective action plans.
Additional Resources
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