The MDS Nurse responsible for completing all facility assessments admitted the errors were "an oversight" after inspectors discovered the falsified records during a complaint investigation in October.
Resident 44 had paralysis on one side of her body and required a two-person assist for transfers using a Hoyer lift. Yet her federal MDS assessment failed to document her paralysis as a functional limitation of range of motion.
The MDS represents a resident's status over a seven-day lookback period and determines their care plan and services. When the MDS Nurse reviewed Resident 44's assessment with inspectors, she acknowledged it was "coded incorrectly because it did not document her paralysis as a functional limitation of range of motion."
"Failure to have the correct diagnosis or an incorrect MDS placed residents at risk for missed services and an inaccurate plan of care," the MDS Nurse told inspectors.
She said she was responsible for completing Resident 44's diagnosis, MDS and care plan.
A second resident's assessment contained similar falsifications. Resident 28, who had severe cognitive impairment with a BIMS score of 0, wandered constantly throughout the facility despite staff documenting she exhibited no wandering behavior.
Inspectors observed the woman walking up and down the 400 hallway at 12:24 p.m., then spotted her in the 100 hallway even though her room was on the 400 hallway. CNA M told inspectors Resident 28 "walked a lot and would walk back and forth in every hallway."
The facility had placed a wander guard bracelet on Resident 28 and developed a care plan specifically addressing her risk for injury from wandering. Staff were ordered to visually check placement of her wandering alert device every shift. Her elopement risk screener noted she had a wandering history.
Yet her quarterly MDS assessment stated wandering behavior was "not exhibited."
After inspectors discovered the discrepancy, staff modified the assessment to show wandering behavior occurred one to three days and documented daily use of a wander/elopement alarm.
The Director of Nursing told inspectors she was familiar with Resident 28 and "she walks all day." She said if the MDS was not accurate, "it was not a direct accurate reflection of who the resident was."
The Social Services Director, who completed multiple sections of the MDS including behavioral assessments, initially defended her documentation. She said she recorded that wandering behavior was not exhibited because Resident 28 "walks the hallways but did not wander outside."
But when pressed by inspectors, she acknowledged something must have happened for the resident to be considered at risk and receive the wanderguard. "If the MDS did not reflect the resident accurately then that was false information because you would not be looking for those behaviors," she said.
The MDS Nurse told inspectors she was going to modify Resident 28's assessment after the violations were discovered.
Federal regulations require facilities to conduct comprehensive, accurate and standardized assessments of each resident's functional capacity. These assessments determine what services residents receive and how much federal funding facilities can claim.
The facility's own policy, dated 2023, requires assessments to be accurate and standardized according to federal regulations.
Both residents' falsified assessments potentially affected their care. Resident 44's undocumented paralysis could have resulted in inadequate physical therapy or mobility assistance. Resident 28's hidden wandering behavior could have left her without proper supervision or safety measures.
The MDS Nurse's admission that the errors were merely an "oversight" came only after inspectors confronted her with evidence of the falsifications during their investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Janisch Health Care Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
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