Federal inspectors found the coding error during a November complaint investigation at Matlock Place Health & Rehabilitation Center on Matlock Road. The resident, identified only as Resident #4, required three daily doses of ipratropium-albuterol inhalation solution and had an albuterol inhaler available as needed for shortness of breath.
Yet his Quarterly Minimum Data Set assessment completed October 31 failed to reflect these respiratory treatments in the special procedures section. The MDS assessment determines what care Medicare pays for and what services nursing homes must provide.
The resident was admitted with senile degeneration of the brain and acute respiratory problems with hypoxia, meaning his blood couldn't maintain proper oxygen levels. His cognitive assessment score of 00 indicated severe impairment. He depended entirely on staff for personal hygiene, toileting, showers, dressing and eating assistance.
Records showed he was receiving hospice palliative care for his terminal brain condition. His medication orders included morphine concentrate solution to be given every hour as needed for pain, along with the respiratory medications.
During the inspection, investigators observed the resident sitting in his wheelchair in the dining room at noon on November 23. He could not be interviewed due to confusion and communication deficits.
The facility's Director of Nursing acknowledged the assessment should have coded the respiratory care the resident was actually receiving. She told inspectors that both she and the Assistant Director of Nursing were responsible for reviewing finalized MDS assessments to ensure accuracy.
"Failing to code the MDS correctly could result in the resident missing care and treatment ordered by the MD," she said during the November 23 interview.
The Administrator echoed this concern when interviewed 10 minutes later. She said her expectation was that MDS assessments "reflect the services, care, and treatment that the resident was receiving at the facility."
"Failing to code correctly could result in the resident missing individualized care," the Administrator stated.
The MDS coordinator was not available for interview since the violation was discovered on a weekend.
Federal regulations require nursing homes to conduct comprehensive assessments of each resident's functional capacity, medical conditions and treatment needs. These assessments, updated quarterly, drive care planning and determine Medicare reimbursement levels.
When respiratory treatments aren't properly documented, facilities may not allocate appropriate staff time or resources for administering breathing medications. The oversight becomes particularly concerning for terminally ill residents whose comfort and symptom management depend on accurate documentation.
The inspection revealed that Matlock Place's policy for maintaining MDS assessments, dated October 1, 2023, failed to address assessment accuracy requirements. This policy gap may have contributed to the coding error that left the resident's respiratory needs undocumented.
The resident's medication record showed his breathing treatments lacked proper dating on the ipratropium-albuterol order, suggesting broader documentation problems beyond the MDS assessment. His care plan from August 8 properly identified his terminal diagnosis and hospice status, making the assessment omission more significant.
For a resident with severe cognitive impairment who cannot advocate for his own needs, accurate documentation becomes the primary safeguard ensuring he receives doctor-ordered treatments. The coding failure created a gap between prescribed care and documented services.
The violation affected multiple residents, according to the inspection findings, though details about other residents were not provided in the available documentation.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. However, administrators' own statements acknowledged that coding failures could result in residents missing necessary medical care and treatment.
The inspection occurred in response to a complaint, suggesting someone raised concerns about assessment accuracy or care delivery at the 7100 Matlock Road facility.
Matlock Place now must submit a plan of correction addressing how it will ensure MDS assessments accurately reflect all services and treatments residents receive. The facility must also demonstrate how it will prevent similar documentation failures that could jeopardize resident care.
The 81-year-old resident remains dependent on staff for all daily activities while receiving end-of-life care for his progressive brain condition. Whether his respiratory treatments are now properly documented in facility assessments was not addressed in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Matlock Place Health & Rehabilitation Center from 2025-11-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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