Failure to Complete Required MDS Assessments
Summary
The facility failed to complete required quarterly assessments for two residents and a significant change Minimum Data Set (MDS) for one resident. Resident #5 did not have any MDS assessments completed after a quarterly MDS on January 9, 2024. The facility's administrator acknowledged that the MDS coordinator had left the position and that no one was monitoring the completion of MDS assessments. The Director of Nursing (DON) was unaware of any incomplete MDS assessments and had only been in the position for a week. Resident #7 was admitted to hospice services on June 21, 2023, but there was no documentation of a significant change MDS being completed after this admission. The resident's records showed multiple entries indicating hospice care, yet the quarterly MDS dated after the hospice admission did not reflect this status. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the DON, revealed a lack of awareness regarding the responsibility and frequency of MDS updates, as well as the absence of a current MDS coordinator.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident did not receive a required quarterly MDS assessment within the mandated 92-day interval. Review of records showed that the assessment was missed, and interviews with the MDS Coordinator and other staff confirmed the omission, with no explanation provided for why the assessment was not completed on time.
Quarterly MDS assessments were not completed within the required timeframe for multiple residents with complex medical conditions, as confirmed by record review and staff interviews.
Quarterly MDS assessments were not completed within the required 92-day interval for a resident, and three other residents had their assessments signed as complete beyond the 14-day window after the ARD. The DON and Administrator acknowledged the delays, citing staff transitions as a contributing factor. Affected residents had complex medical histories, including heart failure, diabetes, dementia, and chronic kidney disease.
The facility failed to complete timely quarterly MDS 3.0 assessments for nine residents, affecting those with conditions like dementia and Alzheimer's. Assessments were either incomplete or overdue, as confirmed by the MDS Coordinator. The RAI Manual mandates quarterly assessments every 92 days, which the facility did not meet, leading to the deficiency.
The facility failed to complete quarterly MDS assessments within the required timeframes for three residents. One resident with dementia had an assessment due on a specific date but completed later, requiring substantial assistance with daily activities. Another resident with schizoaffective disorder and diabetes had a delayed assessment, needing assistance with daily tasks. A third resident with vascular diseases also experienced a delay, despite being cognitively intact. The MDS Nurse confirmed these delays, violating CMS guidelines.
The facility failed to complete MDS assessments within required timeframes for several residents, as identified through medical record reviews and staff interviews. Delays in completing quarterly, admission, and discharge MDS assessments were confirmed by the MDS Coordinator and Regional Nurse, indicating non-compliance with the RAI guidelines.
Missed Quarterly MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment was completed for a resident as required. Record review showed that the resident was originally admitted in early 2021 and most recently readmitted in mid-2024. Examination of the resident's MDS 3.0 assessments revealed that a quarterly MDS was completed in January 2025 and an annual MDS in June 2025, but there was no evidence of any MDS assessments being completed between these dates. According to the MDS Coordinator, a quarterly assessment should have been completed around April 2025, but this was not done, and the coordinator was unable to provide a reason for the omission. The resident was not out of the facility during the time the assessment was due. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Health Services, and Executive Director, confirmed that the responsibility for completing MDS assessments rested with the MDS Coordinator, and that all expected the assessments to be completed on time. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual confirmed that quarterly MDS assessments must be completed at least every 92 days following the previous OBRA assessment. The failure to complete the required quarterly MDS assessment resulted in a deficiency for the facility.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframe of 92 days for nine out of eleven residents reviewed. Record reviews showed that for each of these residents, the last quarterly or annual MDS assessment was not followed by a subsequent quarterly assessment as mandated. The residents affected had various diagnoses, including Parkinsonism, dementia, diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, hypertensive heart disease, hemiplegia, hemiparesis, chronic pain syndrome, Alzheimer's disease, degeneration of the nervous system due to alcohol, epilepsy, congestive heart failure, and asthma. Interviews with the MDS Coordinator confirmed that the required quarterly assessments were not completed for these residents within the specified timeframe. The deficiency was identified through both record review and staff interviews, with the facility census at 66 residents at the time of the survey. No evidence was found in the records to indicate that the quarterly MDS assessments were completed as required for the identified residents.
Plan Of Correction
Residents #11, 20, 21, 22, 26, 29, 41, 42, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 quarterly MDS assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29 quarterly assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. MDS reviewed all quarterly MDS assessments on 5/21/25. Admin provided the MDS Coordinator education on quarterly MDS assessment policy and timely submission. The DON/designee will audit 3 residents' charts weekly to ensure quarterly MDS assessments are submitted timely for 4 weeks. Results will be reviewed in QAPI.
Failure to Complete and Sign Quarterly MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and sign quarterly Minimum Data Set (MDS) assessments within the required federal timeframes for several residents. Specifically, one resident's quarterly MDS assessment was not completed within 92 days of the previous assessment, resulting in the assessment being 27 days overdue. Additionally, three other residents had quarterly MDS assessments that were not signed as complete within 14 days of the Assessment Reference Date (ARD), as required by the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The facility's own policy also mandates adherence to these federal and state submission timeframes. Interviews with the Director of Nursing (DON) and the Administrator confirmed awareness of the overdue and incomplete MDS assessments. The Administrator attributed the delays to recent staff transitions, noting that the current MDS Coordinator had only been in the role for about two weeks. The residents affected had various medical histories, including heart failure, diabetes mellitus, dementia, cerebral infarction, hypertension, chronic kidney disease, and cerebrovascular disease. The deficiencies were identified through record review, policy review, and staff interviews.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) 3.0 assessments were completed in a timely manner for nine residents out of 36 reviewed. These residents included individuals with diagnoses such as dementia, Alzheimer's disease, chronic respiratory failure, Parkinson's disease, cerebral infarction due to embolism, and acquired absence of a limb. The assessments were either incomplete or overdue, as confirmed by the MDS Coordinator during interviews. For Resident #14, the quarterly assessment was in progress but overdue, with the last assessment completed on 06/01/24. Similarly, Resident #15's quarterly assessment was also in progress and overdue, with the last annual assessment dated 05/30/24. Resident #23's quarterly assessment was overdue, with the last admission assessment completed on 05/20/24. Resident #27 had two quarterly assessments listed as in progress, with the last completed assessment being a significant change in status assessment dated 04/03/24. Other residents, such as Resident #30, #47, #52, #56, and #60, also had overdue quarterly assessments, with their last assessments completed several months prior. The RAI Manual requires that quarterly assessments be completed at least every 92 days following the prior OBRA assessment, and the facility's failure to adhere to this requirement resulted in the deficiency noted in the report.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframes for three residents. Resident #26, who has medical diagnoses including dementia and Alzheimer's disease, had an MDS assessment with an Assessment Reference Date (ARD) of 09/07/24, but it was not completed until 09/24/24. This resident was noted to have moderate cognitive impairment and required substantial assistance with daily activities. Similarly, Resident #2, with diagnoses such as schizoaffective disorder and type II diabetes mellitus, had an ARD of 08/23/24, but the assessment was completed on 09/09/24. Resident #9, diagnosed with peripheral vascular diseases, had an ARD of 08/25/24, with the assessment completed on 09/24/24. Both residents were cognitively intact but required varying levels of assistance with daily activities. The MDS Nurse confirmed these assessments were not completed within the 14-day timeframe as required by the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed within the required timeframes, affecting eight residents. The deficiencies were identified through medical record reviews, staff interviews, and a review of the Resident Assessment Instrument (RAI) guidelines. The MDS assessments for these residents were not completed on time, as required by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. For instance, Resident #4's quarterly MDS assessments were consistently completed late, with delays ranging from several days to nearly a month. Similarly, Resident #20's quarterly MDS was completed 21 days after the Assessment Reference Date (ARD), and Resident #30's admission and discharge MDS assessments were also delayed. These delays were confirmed by interviews with the MDS Coordinator, who acknowledged that the assessments were not completed within the required timeframes. The report also highlights that Resident #299's admission assessment was not completed at the time of the review, and Resident #19's quarterly MDS assessments were not completed timely. Additionally, Resident #1's quarterly MDS assessment was signed approximately one month after it was due. Interviews with facility staff, including the MDS Coordinator and Regional Nurse, confirmed these findings and acknowledged that the facility follows the RAI manual guidelines for MDS assessments, yet failed to adhere to the required timelines.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
