The resident, admitted with paraplegia and other conditions, was marked in their September 27 quarterly assessment as scoring a perfect 15 out of 15 on cognitive testing. The same assessment coded them as having "no impairment" in lower extremity range of motion, despite being dependent for bed mobility, transfers, and hygiene.
When asked about walking 10 feet, staff marked the assessment as "not attempted due to medical condition or safety concerns" — the only mobility coding that acknowledged the resident's actual condition.
The resident's comprehensive care plan told a different story. Updated the same day as the flawed assessment, it identified the person as "at risk for falls related to muscle weakness, related to poor balance, related to psychoactive medications." Staff instructions included ensuring the resident wore shoes "when ambulating" and reminding them to use call lights for help with daily activities.
Licensed practical nurse who worked with the resident confirmed the contradiction. When asked what she remembered about the patient, she stated "he could not walk and used a wheelchair."
The MDS coordinator, a licensed practical nurse responsible for completing the assessments, acknowledged the error when inspectors showed her the coding. Asked if there were mistakes in the mobility sections, she replied "yes, there is."
She confirmed staff should follow the Resident Assessment Instrument manual, which requires coding "based on the resident's performance."
The resident had been transferred to a hospital before the October inspection and was not at the facility during the survey.
Federal minimum data set assessments determine Medicare reimbursement rates and care planning requirements. Facilities receive higher payments for residents requiring more intensive services, while coding errors can mask actual care needs or inflate reported capabilities.
The assessment coding suggested the resident had full cognitive function and minimal physical limitations, contradicting both the care plan's fall prevention protocols and staff observations of wheelchair dependency.
Inspectors classified the violation as causing minimal harm or potential for actual harm. The facility's director of nursing, administrator, and assistant director of nursing were notified of the findings on October 22.
The inspection report provided no information about how long the inaccurate assessment remained in the resident's record or whether similar coding errors affected other patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westport Rehabilitation and Nursing Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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