Failure to Complete Timely Quarterly MDS Assessments
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) Assessments were completed in a timely manner for seven residents out of a sample of 33. During a review on June 27, 2024, it was found that there was no evidence of Quarterly MDS assessments for two residents. An interview with MDS Nurse J confirmed that the last MDS assessment for one resident was transmitted on January 15, 2024, with a quarterly assessment due on April 16, 2024, which was never opened. Similarly, for another resident, the last assessment was transmitted on February 15, 2024, with a quarterly assessment due on May 17, 2024, which was not completed. MDS Nurse J stated that the assessments were tracked using a 30-day electronic MDS scheduler report run each month. A review of this report showed that seven residents were overdue for quarterly assessments, indicating a failure to adhere to the facility's policy of conducting assessments no less than every three months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to complete required quarterly MDS assessments within 14 days of the ARD for multiple residents. Record review showed that several residents had quarterly MDS assessments initiated and marked as "in progress" but not finalized by the regulatory deadline. Two MDS coordinators, who share responsibility for transmitting MDS assessments, acknowledged the incomplete status and attributed delays in part to a transition in job duties. The DON and the Administrator were aware that some MDS assessments were behind or past due and stated that their expectation was for MDS assessments to be completed on time.
A resident’s quarterly MDS assessment was not completed by the required due date. Review of the EHR showed the assessment was overdue, and during interview the DON confirmed that the quarterly MDS had been due and was not completed as required. This issue was identified during a review of multiple residents’ assessment accuracy and completion.
A resident with parkinsonism and DM did not have a quarterly MDS assessment completed within the required timeframe. Facility policy required quarterly comprehensive assessments to be completed within 92 days of the last assessment, but documentation showed the resident’s next quarterly assessment, listed as due and in progress, was not completed by the due date. During interview, the MDS coordinator confirmed the assessment was overdue and should have been completed as scheduled.
A resident did not receive a required quarterly MDS assessment within three months of the admission assessment. Record review showed multiple documented assessments and entries, but no quarterly assessment after admission. An LPN temporarily responsible for MDS assessments and care plans while the MDS coordinator was on leave reported being unaware that the quarterly MDS for this resident was due, and the DON confirmed the assessment was late because the interim MDS nurse did not complete the required duties.
Surveyors found that quarterly MDS assessments were not completed within the required timeframe for three residents, with each assessment finalized more than 14 days after the ARD. Review of electronic records showed delayed completion dates for these quarterly assessments, and during interviews the MDS RN and regional clinical staff confirmed the assessments were late. Staff reported that a high volume of new admissions contributed to falling behind on required MDS work, and leadership acknowledged that additional improvement was needed to ensure timely completion.
The facility did not complete quarterly MDS assessments within the required 92-day timeframe for two residents. Record review showed that the interval between two quarterly MDS ARDs for a resident was 94 days, exceeding regulatory limits and the facility’s MDS 3.0 Completion policy. The RN VP of Clinical Reimbursement confirmed the assessments were late, and leadership acknowledged that assessments are expected to be completed on time to meet regulatory requirements and support timely care planning.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for 10 of 24 residents reviewed. Record review showed that multiple residents had quarterly MDS assessments with established ARDs that remained in an “in progress” status and were not completed. Specifically, residents identified in the report had quarterly MDS assessments with ARDs ranging from mid-January through late February that were not finalized within the required timeframe. Each cited resident’s quarterly assessment was initiated and assigned an ARD, but the documentation showed the assessments were left incomplete beyond the regulatory deadline. During interviews, two MDS Coordinators stated they were both responsible for transmitting MDS assessments and acknowledged that the cited assessments were incomplete. One MDS Coordinator explained that the assessments were not finished due to transitioning from previous job duties. In a separate interview, the DON and the Administrator each acknowledged awareness that some MDS assessments were behind or past due, and both stated their expectation that MDS assessments be completed timely to meet federal regulations. The report does not provide additional clinical details or medical histories for the affected residents beyond their admission dates and the status of their quarterly MDS assessments.
Failure to Complete Quarterly MDS Assessment by Required Due Date
Penalty
Summary
The facility failed to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment was completed by the required due date. Record review of the resident’s electronic health record showed that a quarterly MDS assessment was due to be completed by 02/16/26. However, the assessment was not completed by that date. During an interview on 03/09/26 at 12:35 pm, the Director of Nursing (DON) confirmed that the quarterly MDS assessment had been due on 02/16/26 and acknowledged that it was not completed as required. This failure to complete the quarterly MDS assessment as scheduled was identified for 1 of 3 residents reviewed for assessment accuracy and completion, and the report states that this deficient practice is likely to result in residents not receiving care and treatment that meet their current needs.
Failure to Complete Required Quarterly MDS Assessment on Time
Penalty
Summary
The facility failed to complete a required quarterly MDS assessment within the mandated timeframe for one resident. Facility policy titled "MDS 3.0 Completion" required that quarterly comprehensive assessments be completed no greater than 92 days from the resident’s last quarterly assessment. Record review showed that a resident with diagnoses including parkinsonism and diabetes mellitus had a quarterly assessment dated 11/18/25, and the facility’s comprehensive assessment list indicated the next quarterly assessment was due by 02/18/26 and was still listed as in progress after that date. On 03/05/26 at 7:55 a.m., the MDS coordinator confirmed that the resident’s quarterly assessment was due on 02/18/26 and acknowledged it should have been completed by that time. This deficiency involved one of three sampled residents reviewed for quarterly assessments, in a facility with 52 residents, and was based on record review and staff interview demonstrating noncompliance with the facility’s own MDS completion policy and the required quarterly assessment schedule.
Missed Quarterly MDS Assessment Due to Interim Staff Oversight
Penalty
Summary
The facility failed to complete a required quarterly MDS assessment for one resident, resulting in the resident not having an updated assessment within three months of the admission assessment. Record review showed an admission assessment dated 09/28/25, an annual assessment, a discharge with return anticipated dated 11/06/25, and an entry dated 11/19/25 for this resident, but no subsequent quarterly assessment was documented. During interview, an LPN who was one of two interim nurses assigned to perform MDS assessments and care plans while the MDS coordinator was on leave stated they were not aware that this resident’s quarterly MDS was due. The DON confirmed that the quarterly assessment for this resident was late because the interim MDS nurse did not perform the required assessment duties.
Untimely Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for three of thirty sampled residents. For one resident, the electronic medical record showed a quarterly MDS with an ARD of 09/29/25 that was not marked as completed until 10/22/25. For a second resident, the quarterly MDS had an ARD of 11/15/25 and was not completed until 12/04/25. For a third resident, the quarterly MDS had an ARD of 11/07/25 and was not completed until 12/02/25. These completion dates exceeded the regulatory timeframe tied to the ARD for quarterly assessments. During a joint interview on 02/19/26, the MDS RN and Regional MDS Consultant confirmed that the quarterly MDS assessments for these three residents were not completed within the required regulatory timeframe. The MDS RN stated that the facility had experienced a high volume of new admissions and that staff had fallen behind on the number of MDS assessments needing completion. In a subsequent interview on 02/20/26 with the Administrator present, the Regional Director of Clinical Operations acknowledged that, despite good-faith efforts to address MDS issues, further improvement was still needed in completing assessments within regulatory timeframes.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required regulatory timeframe for two of three sampled residents. For one resident, the Electronic Health Record showed an admission date followed by a series of MDS assessments with Assessment Reference Dates (ARDs) including quarterly and annual assessments. Review of these ARDs revealed that the interval between the quarterly assessment dated 12/21/2024 and the subsequent quarterly assessment dated 3/25/2025 was 94 days, which exceeded the 92-day regulatory limit for OBRA-required assessments. This delay meant the quarterly assessment was not completed within the timeframe specified by regulation and the facility’s own policy. During interviews, the RN Vice President of Clinical Reimbursement confirmed that the quarterly assessments were late by two days, acknowledging there were 94 days between the ARDs instead of the required maximum of 92 days. The Administrator and the National Director of Risk Management stated that the facility’s expectation is that assessments are completed on time and referenced the potential negative outcomes of failing to meet regulatory requirements and ensuring appropriate care planning within required timeframes. Review of the facility’s policy titled “MDS 3.0 Completion” showed that annual assessments must use an ARD no more than 366 days from the most recent comprehensive assessment and no more than 92 days from the most recent quarterly assessment, and that quarterly assessments must use an ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment, confirming that the 94-day interval was out of compliance.
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