The resident, identified as Resident #1 in the November inspection report, scored 15 on a cognitive assessment indicating he was mentally intact. During an interview on November 7, he told inspectors about his fall from bed but said he wasn't hurt and didn't need hospital treatment.
His care plan told a different story than his federal assessment. The comprehensive care plan, last reviewed September 9, identified him as being "at risk for falls" with interventions dated October 7 including a "bolster/scoop mattress for safe boundaries to minimize risk for rolling out of bed."
When inspectors observed him on November 7 at 1:21 p.m., the resident was lying on an air mattress equipped with the bolsters described in his care plan, with his call light within reach.
The registered nurse assessment coordinator who completed his quarterly MDS assessment signed it as finished November 3, with an observation period ending October 27. Under the section asking about any falls since admission or the prior assessment, she marked that he had not fallen.
But she knew about the fall.
During an interview November 10, the assessment coordinator told inspectors she learns about resident falls by attending morning interdisciplinary team meetings and reviewing risk management reports. She acknowledged that "for Resident #1, she coded there was no falls, but he did have a fall according to a risk management report."
She defended the error, telling inspectors that miscoding a resident's fall history wouldn't impact his care if the fall was addressed in his care plan with appropriate interventions. The staff provide care according to the care plan, she said, not the federal assessment.
The director of nursing echoed this reasoning during her November 10 interview. A documentation error on fall history wouldn't impact resident care if interventions were care-planned, she told inspectors.
The administrator took the same position during her interview, stating there would be no impact on care if the MDS assessment's fall history was incorrect as long as the care plan was accurate. If the care plan contained the right interventions, she said, the direct care team would know what to do following the fall.
The facility's own policy contradicted this casual attitude toward assessment accuracy. The comprehensive assessment policy, revised in March 2023, states that "each resident receives an accurate team member assessment" and that "MDS information is the clinical basis for each resident's care planning and delivery."
The policy requires that "a registered nurse signs and certifies that the assessment is completed" and that "everyone who completes a portion of the assessment also signs and certifies the accuracy of that portion of the assessment."
Most significantly, the policy makes clear that "each individual assessor is responsible for certifying the accuracy of responses on the forms relative to the resident's condition."
The registered nurse assessment coordinator had signed and certified the accuracy of an assessment that contradicted both the resident's own account and the facility's risk management documentation.
Federal MDS assessments serve as the foundation for Medicare reimbursement and care planning requirements. The assessments are supposed to provide an accurate snapshot of each resident's condition, including fall risk and history.
The inspection found that despite having documentation of the resident's fall in risk management reports and implementing fall prevention interventions in his care plan, the facility submitted federal paperwork claiming he had never fallen.
The resident remained in his bed with bolster mattress boundaries, his call light within reach, while facility managers insisted to inspectors that coding errors on federal assessments don't matter as long as care plans are correct.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stone Oak Care Center from 2025-11-25 including all violations, facility responses, and corrective action plans.