Even small mistakes in Minimum Data Set assessments can carry big consequences, and the Centers for Medicare and Medicaid (CMS) is paying closer attention.
CMS recently implemented updated surveyor guidance that directs surveyors to scrutinize the accuracy of Minimum Data Set (MDS) assessments more closely than ever before. Specifically, surveyors are instructed to compare MDS entries—such as resident functional status, diagnosis coding, and behavior reporting—against clinical records to verify accuracy. If mismatches occur repeatedly, facilities could face penalties like reduced reimbursement and government investigation.
For long-term care facilities that receive federal funding, this means the MDS—a standardized assessment tool used to collect essential information about residents—is a high-stakes regulatory tool. By identifying and avoiding common errors, facilities can strengthen compliance, protect residents, and safeguard their reputation.
Let’s walk through five of the most common MDS errors—and how to avoid them.
MDS sections G and GG document residents' performance of daily tasks like walking and dressing. This data impacts care planning, therapy services, and PDPM (Patient Driven Payment Model) reimbursement.
Common mistake: Nursing staff and therapists record different levels of assistance. For example, therapy staff may code “supervision,” while nursing charts “extensive assistance.”
Why it matters: Under CMS’s updated guidance, surveyors are now checking whether MDS coding matches clinical documentation. Inconsistencies may signal poor interdisciplinary communication or worse—inaccurate coding. Incorrect coding of functional status can misrepresent resident needs, causing insufficient care or unnecessary resource allocation.
How to avoid it:
Section I captures all current medical diagnoses that directly impact resident care. Accurate coding in this section informs case-mix classifications and guides the selection of appropriate clinical interventions.
Common mistake: Coding outdated, resolved, or unverified diagnoses—or missing active ones
Why it matters: New CMS survey guidance instructs surveyors to confirm diagnosis codes with the medical record. Unsupported diagnoses may lead to payment recoupments or citations.
How to avoid it:
Section J addresses falls, pain intensity, and related interventions—critical areas for resident safety, dignity, and quality of life.
Common mistake: Underreporting minor or unwitnessed falls, or defaulting to “no pain” without proper resident input.
Why it matters: Falls and pain are two of the clearest indicators of resident well-being. When they’re underreported or inaccurately coded, residents may miss out on timely interventions that directly affect safety and comfort. In addition, surveyors may interview residents and compare MDS responses to actual outcomes. If the MDS says “no pain” but progress notes show pain medications were given regularly, that’s a red flag.
How to avoid it:
When a dash or caret code is used in place of a response, it signals that data is unavailable. While sometimes necessary, it’s often used too liberally.
Common mistake: Using placeholder codes when valid information is available.
Why it matters: Frequent use of dash codes may trigger MDS rejection or audit attention. CMS expects facilities to make every effort to provide complete data.
How to avoid it:
This is the most avoidable—and most cited—issue. The MDS must reflect what’s in the resident’s progress notes, care plan, and assessments.
Common mistake: MDS states a resident is independent in toileting, but CNA documentation says they need extensive assistance.
Why it matters: CMS surveyors are now comparing MDS entries directly against charting. Discrepancies are considered documentation errors and may lead to compliance violations.
How to avoid it:
The MDS is more than a form. It’s a tool that reflects the real condition of your residents and the quality of your care. With CMS placing sharper focus on accuracy, small inconsistencies can quickly become big problems: survey citations, payment recoupments, or public Five-Star hits. But at the core, inaccurate MDS entries mean residents may not get the right care, at the right time.
By avoiding these five common errors, your team can:
Accuracy requires ongoing practice and staff confidence. Showd.me’s MDS training series equips your team with the tools to code consistently, document effectively, and approach survey readiness with confidence. Each course is short, practical, and designed for frontline nurses, MDS coordinators, and therapy staff alike.
Interested in learning more about how Showd.me is helping providers deliver the essential education their staff need? Click here to learn more about our unique managed service approach to training and request a demo today!