The resident arrived September 19 with colon cancer, a colostomy, and surgical aftercare needs. Hospital discharge papers showed the patient had wounds on both buttocks — a right buttock wound and a left buttock deep tissue injury.
But when the Director of Nursing conducted the actual admission assessment that same day, she found something different. The resident had a surgical incision on the abdomen and a stage two pressure ulcer on the left armpit area. No wounds appeared on either buttock.
The MDS nurse responsible for the official Medicare assessment never examined the resident herself.
MDS Registered Nurse #264 told inspectors she had not assessed the resident but documented wounds anyway. She recorded that the resident had a stage two pressure ulcer and a deep tissue injury, pulling this information directly from the hospital paperwork rather than the facility's own clinical findings.
When inspectors asked what should be documented when hospital records and clinical assessments disagreed, the MDS nurse said she was unsure. She was still in training.
The discrepancy created false medical records. The official Medicare assessment showed one surgical wound, one stage two pressure ulcer, and one unstageable deep tissue injury. The actual clinical assessment found a surgical incision and one stage two pressure ulcer in a completely different location.
Inspectors observed the resident on October 8 with the Director of Nursing present. They found a surgical wound on the abdomen and a scabbed area on the left armpit. The resident's buttocks showed no pressure areas at all.
The Director of Nursing confirmed to inspectors that she had completed the admission wound assessment. She verified the resident had no pressure ulcer or deep tissue injury on either buttock when admitted.
Hospital documentation can be wrong. Discharge summaries sometimes describe wounds that have healed or list injuries that were suspected but never confirmed. Federal regulations require nursing homes to conduct their own assessments specifically because what patients arrive with may differ from what hospitals report.
The resident had intact cognition, according to the assessment. They would have known whether wounds on their buttocks existed or caused pain.
Regional MDS Nurse #266 acknowledged the admission assessment was incorrect during her interview with inspectors. She said the discrepancy between hospital documentation and clinical assessment should have been addressed before completing the official Medicare forms.
She told inspectors a modification of the admission assessment would be completed.
The facility's own policy, revised in November 2019, required all care team members to participate in resident assessments. The resident assessment coordinator was responsible for ensuring the interdisciplinary team conducted timely and appropriate assessments and reviews.
MDS assessments determine Medicare reimbursement rates and care planning. Facilities receive higher payments for residents with more complex medical needs, including pressure ulcers. The assessments also guide treatment decisions and staffing assignments.
False documentation of wounds that don't exist can lead to unnecessary treatments, incorrect medication orders, and inappropriate care plans. It can also mask actual problems when staff expect to find documented wounds but discover different conditions.
The 36-bed facility received a minimal harm citation for the assessment failure. Federal inspectors reviewed three residents' admission assessments and found problems with one case.
The violation occurred during a complaint investigation, suggesting someone reported concerns about care quality or documentation practices at the facility.
Training gaps emerged as a central issue. The MDS nurse told inspectors she was unsure how to handle conflicting information between hospital records and clinical findings — a common situation in nursing home admissions that should be covered in basic training programs.
The resident assessment coordinator's role includes ensuring proper training and oversight of assessment processes. The failure to catch the discrepancy before submission suggests gaps in supervisory review as well.
Medicare assessments create permanent medical records that follow residents throughout their care. Once submitted, corrections require formal modification processes and can affect historical data used for quality measurements and regulatory oversight.
The case illustrates how documentation errors can compound when staff rely on external records rather than direct patient observation, particularly when training and supervision systems fail to catch fundamental mistakes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Care Center from 2025-10-09 including all violations, facility responses, and corrective action plans.