Bywood East Health Care: MDS Documentation Failures - MN
That admission came from the director herself.
When inspectors interviewed the director of nursing on October 23, 2025, she confirmed she had reviewed a resident's medical record and the corresponding Minimum Data Set, the federal assessment form nursing homes use to track every resident's health status and care needs. She had signed the MDS as completed. But when asked whether she had checked the form before signing it, she said she had not. "I wasn't looking at them," she told inspectors.
The MDS in question belonged to a resident identified in inspection records as R2, who had an ankle wound and was considered at risk for pain. Sections of the assessment had been left blank, marked with dashes rather than actual data. Among the missing components were the BIMS, a standardized cognitive screening tool, and the PHQ-9, a depression and mood assessment. Both are supposed to be completed within a specific window tied to the assessment reference date so the results can be recorded accurately on the MDS.
The director of nursing confirmed to inspectors that skipping those assessments or entering incorrect data was not a minor clerical issue. Incomplete entries, she said, could affect which Care Area Assessments get triggered, the follow-up evaluations that determine whether a resident needs a formal care plan for pain, mood problems, cognitive decline, or other conditions. If the data going into the MDS is wrong, or simply missing, those triggers may never fire.
When inspectors pressed her on this, she did not hedge. "Correct, 100 percent," she said.
The facility's own internal MDS review policy, which inspectors obtained, had no date on it. The policy stated the facility would ensure assessments were completed using current, accurate documentation specific to each resident, and it assigned the social services department responsibility for documenting cognition, behavior, mood, and adjustment outcomes, the same categories covered by the BIMS and PHQ-9 that were missing from R2's file.
The director of nursing told inspectors the facility had only recently hired a new MDS coordinator and expressed confidence the situation would improve. She also said that on the same day inspectors interviewed her, October 23, she had just begun a Performance Improvement Plan targeting MDS completion. The inspection had been prompted by a complaint.
What the record shows is a director who was signing off on federal assessments, documents that shape every aspect of a resident's care plan, without checking whether the required sections had actually been filled in. For R2, a person already dealing with an open wound and documented pain risk, the gap between what the MDS should have captured and what it actually recorded was not hypothetical. The director acknowledged it directly: inaccurate or missing data meant the facility might not have known what care that resident needed, or whether their condition was changing.
The MDS coordinator position had apparently been vacant or in transition long enough that the assessments had fallen behind. The director's solution, a performance improvement plan started the morning inspectors arrived, may yet address the problem. But R2's assessment had already been signed, filed, and treated as complete.
Nobody had been looking at them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bywood East Health Care from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 28, 2026 · Our methodology
BYWOOD EAST HEALTH CARE in MINNEAPOLIS, MN was cited for violations during a health inspection on November 20, 2025.
That admission came from the director herself.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.