Failure to Timely Complete Quarterly MDS Assessments
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments within the required timeframe for two residents. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the quarterly MDS should be completed within 92 days after the Assessment Reference Date (ARD) of the previous MDS, and the completion date should be no later than 14 days after the ARD. However, for Resident #6, the quarterly assessment was completed 19 days after the ARD, and for Resident #135, the assessments were completed 26 and 17 days after the ARD for two separate quarters. During the survey, the part-time MDS Coordinator/RN acknowledged the late submissions and stated that the facility follows the RAI Manual guidelines. The Director of Nursing also recognized the issue of late completion and submission of MDS assessments. Despite these acknowledgments, the facility did not provide additional information or refute the findings during the exit conference with the survey team, which included the Licensed Nursing Home Administrator, Chief Nursing Officer, Corporate Compliance Officer, and Regional Administrator.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment and diagnoses including Alzheimer's disease, dementia with agitation, type 2 DM with nerve damage, and HTN had a quarterly MDS completed 29 days late. The DON stated quarterly MDSs are tracked in PCC and are used to monitor resident status and quality outcomes, but acknowledged the assessment was missed when the facility's assessment calendar reset and it was not identified as due.
Untimely MDS assessments were identified for three residents. One resident had only the admission MDS completed, another resident had no MDS after admission, and a third resident had no quarterly MDS after the last completed assessment. An LPN confirmed the missing assessments.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required timeframe for seven residents. The assessments were completed after the allowed deadline, and the NHA confirmed the MDSs were not completed in the required time frames.
A resident with diagnoses including a right femur fracture, muscle weakness, and low back pain did not receive an MDS assessment at least every 3 months. The record showed a quarterly MDS followed by an annual MDS without an intervening quarterly assessment, and the MDS Coordinator and DON both stated assessments should be completed quarterly.
Missed Quarterly MDS Assessment: The facility failed to complete a resident’s quarterly MDS within the required timeframe. The MDS Coordinator said the EHR tracking system did not exist, and the DON/Administrator reported there was no facility policy for MDS assessments, with staff relying on the RAI Manual, which requires the quarterly MDS every 3 months.
RN/MDS coordinator review showed multiple MDS assessments were not signed by an RN within the required 14-day timeframe after the ARD for numerous residents, including quarterly, annual, PPS, significant change, and entry tracking assessments. The facility also failed to complete a discharge MDS for a resident who was transferred to the hospital and did not return; the RN/MDS coordinator confirmed the omission.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed within the required timeframe for one resident. The resident had an initial admission date of 3/18/24 and an MDS that identified moderate cognitive impairment along with diagnoses including Alzheimer's disease, dementia with agitation, type 2 diabetes with nerve damage, and high blood pressure. Document review showed the resident's previous quarterly assessment was dated 3/24/26, making the next quarterly assessment due by 6/24/26; however, it was not completed until 7/23/26, 29 days late. During interview, the DON stated quarterly MDS assessments are completed every three months in accordance with the RAI schedule and are used to monitor resident status and quality outcomes, and acknowledged the assessment was missed because the facility's assessment calendar reset and the assessment was not identified as due.
Untimely MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed timely for three residents reviewed. Resident 23 was admitted to the facility and had an admission MDS completed on admission, but the clinical record did not show any further MDS completed after March 13, 2026. Resident 33 was admitted and had an admission MDS completed on January 27, 2026, but no further MDS assessment was found in the record after admission. Resident 34 had a quarterly MDS completed on March 10, 2026, but the record did not show any additional MDS completed after that date. A Licensed Employee confirmed on July 30, 2026, that no further MDS had been completed for Resident 23 and that the quarterly assessments were not completed for Residents 33 and 34.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments were completed within the required time frame for seven of 87 residents reviewed: Residents 56, 74, 85, 96, 119, 130, and 141. The RAI User's Manual stated that the ARD for a quarterly MDS must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment completion date must be no later than the ARD plus 14 calendar days. For Resident 56, the quarterly MDS had an ARD of May 26, 2026, but was completed on June 10, 2026, two days late. Resident 74's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. Resident 85's quarterly MDS had an ARD of June 28, 2026, but was completed on July 13, 2026, two days late. Resident 96's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. Resident 119's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. Resident 130's quarterly MDS had an ARD of June 3, 2026, but was completed on June 18, 2026, two days late. Resident 141's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. The Nursing Home Administrator confirmed in interview that these comprehensive MDS assessments were not completed in the required time frames.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly review assessment at least once every 3 months for one resident. Resident 6 had diagnoses including displaced intertrochanteric fracture of the right femur, initial encounter for a closed fracture, muscle weakness, and low back pain. Her clinical record showed a Quarterly MDS assessment completed on March 10, 2026, followed by an Annual MDS assessment completed on July 16, 2026, with no quarterly assessment completed in between. During an interview, the MDS Coordinator stated the resident should have had an assessment completed every 3 months, and the DON stated she would expect MDS assessments to be completed at least quarterly.
Missed Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessment within the required timeframe for 1 of 1 residents reviewed, Resident #34. The resident’s MDS report in the EHR showed the last MDS assessment was completed on 3/4/26, and the current quarterly MDS had not been completed. During record review and staff interviews, the MDS Coordinator stated on 7/13/26 that the tracking system in the EHR did not exist, which caused the facility to miss the quarterly MDS. The Administrator stated on 7/13/26 that staff should complete the MDS within the required timeframe and reported the facility did not have a policy for MDS assessments, instead following the RAI Manual. The RAI Manual dated October 2025 instructed that the quarterly MDS be completed every 3 months.
Late RN Signatures on MDS Assessments and Missing Discharge Assessment
Penalty
Summary
The facility failed to ensure that MDS assessments were signed by an RN within 14 days after the ARD for 19 of 19 sampled residents. Record review showed multiple quarterly, annual, PPS, significant change, and entry tracking MDS assessments with RN signature completion dates that occurred more than 14 days after the ARD. Examples included residents whose quarterly and annual assessments were signed late, as well as a resident whose entry tracking assessment was signed after the required timeframe. RN/MDS coordinator D confirmed she was responsible for reviewing each resident’s MDS for completion and signing the Z0500 section, and she acknowledged that the MDSs were not always signed within the 14-day requirement. The facility also failed to complete a discharge assessment for one resident who was transferred to the hospital and did not return. Record review showed the resident was transferred to the hospital, did not return to the facility, and was discharged, but no discharge return anticipated or return not anticipated MDS assessment was completed. During interview, RN/MDS coordinator D confirmed that no discharge MDS had been completed and stated, "I must have missed that."
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