Failure to Complete Annual MDS Assessment on Time
Summary
The facility failed to complete and submit the annual comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe for a resident. The resident was originally admitted on November 3, 2023, and readmitted on May 17, 2024, with diagnoses including epilepsy, bipolar disorder, hemiplegia, and hemiparesis. The resident was totally dependent on staff for all activities of daily living and had severely impaired cognition. The last MDS assessment for the resident was completed on July 30, 2024, and the annual assessment was overdue as it should have been completed by November 1, 2024. During a review with the MDS Coordinator, it was confirmed that the annual MDS assessment was overdue, and the coordinator acknowledged that the MDS is a complete record of the resident's care. The Director of Nursing also stated that the MDS should be completed and submitted according to CMS timeframes. The facility's policy and procedures, as well as the MDS/RAI Coordinator's job description, indicated that assessments should be completed and transmitted within required timeframes, which was not adhered to in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident’s required annual MDS assessment was not completed on time. Review of the EMR showed the annual assessment was due after the prior quarterly MDS, but there was no evidence it was completed within the required timeframe. The MDS Coordinator/RN stated the facility used a monthly report and due-date schedule to track assessments, but acknowledged the resident fell through the cracks and the annual MDS appeared to have been missed.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
Surveyors found that the facility failed to complete and submit accurate final discharge MDS assessments for two residents who were discharged to the hospital and did not return. In both cases, the discharge MDSs incorrectly indicated a status of return anticipated, and no subsequent final discharge MDSs reflecting return not anticipated were completed, despite documentation in the EHR that the residents did not come back. The DON acknowledged that MDS assessments are expected to accurately reflect residents’ current status because inaccuracies can affect billing and census, and confirmed that these two discharge assessments were inaccurate.
A resident admitted with hemiplegia after cerebral infarction, anxiety disorder, myasthenia gravis, and dysphagia did not have a timely completed admission MDS 3.0 assessment. Record review showed the admission MDS remained in process past the required 14-day completion timeframe, with multiple sections (including A, B, H, I, J, L, M, N, O, P, S) and the CAA summary in Section V incomplete and the document unsigned. The MDS Coordinator confirmed the assessment was overdue, in contrast to RAI User’s Manual requirements.
Incomplete Admission Comprehensive Assessment: A resident with CVA, nontraumatic subarachnoid hemorrhage, and HTN had an admission comprehensive assessment that remained in progress and was not completed by the required deadline. The MDS showed severely impaired cognitive skills and extensive assistance needs for ADLs, and the AMDS confirmed the assessment could not be closed because four areas, including Social Services and Dietary, were still incomplete.
The facility failed to complete required MDS admission, quarterly, and annual assessments within 14 days of the ARD for six residents. One admission MDS was completed several days late, and multiple quarterly and annual MDS assessments remained incomplete past their required due dates. An LPN acknowledged knowing the 14‑day requirement and reported that she did not complete or delegate the assessments before going on vacation. The DON confirmed the 14‑day completion requirement and stated unawareness that the MDSs were overdue, while facility policy assigns responsibility for timely MDS completion to the MDS Coordinator.
Missed Annual MDS Assessment
Penalty
Summary
The facility failed to ensure timely completion of a required annual MDS assessment for one resident, R7. R7’s most recent MDS was a quarterly assessment dated [DATE], and based on the assessment schedule, an annual MDS was required after the 12/2/25 quarterly assessment. Review of R7’s EMR and MDS records showed no evidence that the annual assessment was completed within the federally required timeframe. During interview, the MDS Coordinator and RN-B stated that the EMR system generated a monthly report on the 15th to track upcoming MDS assessments and that a schedule with due dates was then completed for nursing staff to gather data and identify ARDs. RN-B stated he was unsure how R7 fell through the cracks, acknowledged that the annual assessment appeared to have been missed, and said he would complete it immediately.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Complete Accurate Final Discharge MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete and submit accurate comprehensive Minimum Data Set (MDS) discharge assessments for two residents who were discharged to the hospital and did not return. For the first resident, the face sheet showed an admission date of 09/16/24 and a discharge date of 02/24/26. The discharge MDS, dated with a specific discharge date, documented the resident as discharged to the hospital with a status of return anticipated. However, review of the resident’s Electronic Health Record (EHR) as of 04/27/26 showed the resident did not return to the facility, and a final discharge MDS with a status of return not anticipated was not completed or submitted as required. For the second resident, the face sheet showed an admission date of 02/24/26 and a discharge date of 03/14/26. The discharge MDS, dated with a specific discharge date, also documented a discharge to the hospital with a status of return anticipated. EHR review as of 04/27/26 revealed this resident likewise did not return to the facility, and a final discharge MDS reflecting a return not anticipated status was not completed or submitted. During an interview on 04/27/26 at 2:33 pm, the DON stated that her expectation was for MDS assessments to accurately reflect the resident’s current status in the facility because inaccurate status could affect billing and census, and she acknowledged that the discharge MDS assessments for these two residents were inaccurate and should have indicated discharge–return not anticipated.
Untimely and Incomplete Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a timely admission Minimum Data Set (MDS) 3.0 assessment for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, anxiety disorder, myasthenia gravis without exacerbation, and dysphagia. Medical record review on 04/22/26 showed that the admission MDS 3.0 had an assessment reference date of 04/12/26 and was still identified as in process, with a required completion date of 04/19/26. Multiple sections of the MDS (A, B, H, I, J, L, M, N, O, P, S) remained incomplete, the Care Area Assessment (CAA) summary in Section V was not completed, and the document was unsigned. Interview with the MDS Coordinator confirmed that the admission MDS assessment for this resident had not been completed and was overdue. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.18.11, dated October 2023, indicated that an admission assessment must be completed within 14 days of admission, with the admission date counted as day one. This untimely and incomplete admission MDS assessment was identified as an incidental example of non-compliance during a complaint investigation.
Incomplete Admission Comprehensive Assessment
Penalty
Summary
The facility failed to complete an admission comprehensive assessment within the required timeframe for one of three sampled residents, Resident 211. The resident’s Face Sheet showed admission with diagnoses including cerebral infarction, nontraumatic subarachnoid hemorrhage, and hypertension. The Minimum Data Set dated 4/21/2026 indicated the resident had severely impaired cognitive skills for daily decision making and required a helper to do all of the effort for toileting hygiene, showering/bathing, dressing, sit-to-lying, and lying-to-sitting on the side of the bed. During a concurrent interview and record review on 4/23/2026 at 12:50 p.m., the Assistant MDS Nurse reviewed the admission comprehensive assessment dated 4/21/2026 and confirmed it was still in progress and not completed. The AMDS stated the assessment should have been completed on 4/22/2026 but could not be closed because four areas were incomplete, including sections from Social Services and Dietary. The CMS RAI version 2.0 stated the admission comprehensive assessment was to be completed no later than 13 days after the admission date, which was 4/22/2026.
Untimely Completion of Required MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive MDS assessments within 14 days of the Assessment Reference Date (ARD) for six sampled residents. For one resident, the admission MDS had an ARD of 3/18/26 and was required to be completed by 4/1/26, but was not completed until 4/6/26, making it five days late. For another resident, a quarterly MDS with an ARD of 4/1/26 and a due date of 4/15/26 had still not been completed as of 4/20/26, making it five days late. A third resident’s quarterly MDS, with an ARD of 4/2/26 and a due date of 4/16/26, also remained incomplete as of 4/20/26, four days past the required completion date. Additionally, three other residents had overdue assessments: one resident’s annual MDS with an ARD of 4/4/26 and due date of 4/18/26 was still incomplete on 4/20/26, two days late, and two residents’ quarterly MDS assessments with the same ARD and due date were also not completed by 4/20/26, each two days late. The MDS nurse (LPN) acknowledged that admission, quarterly, and annual MDS assessments are due within 14 days of the ARD and stated she did not complete these assessments before going on vacation and did not delegate them to the MDS Coordinator. The DON confirmed that each MDS should be completed within 14 days of the ARD, reported being unaware that MDSs were not being completed on time, and stated that the LPN should have delegated the assessments. Facility policy dated 7/2023 specifies that MDS assessments must be completed within 14 days for new admissions and reviewed quarterly and annually, with the MDS Coordinator responsible for timely completion.
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