Failure to Complete Timely MDS Assessments Due to EMR Downtime
Summary
The facility failed to complete a comprehensive annual Minimum Data Set (MDS) assessment for two residents, R18 and R21, within the required regulatory timeframe. R18's annual MDS was due on May 15, 2024, but was not completed and submitted until July 18, 2024, during the recertification survey. Similarly, R21's annual MDS was due on May 8, 2024, but was not completed and submitted until July 15, 2024. This delay resulted in the absence of timely annual comprehensive assessments, which are necessary for reviewing and updating care plans based on the residents' current needs. The facility's failure to complete these assessments in a timely manner was attributed to a lack of access to electronic medical records (EMR) from May 8, 2024, to June 28, 2024, during which the MDS Registered Nurse (RN-G) was working at another facility. The surveyor's investigation revealed that the facility did not have a documented process for completing and submitting MDS assessments during EMR downtime. Although the facility had an EMR Disaster and Downtime Process, it did not include instructions for handling MDS assessments. The Nursing Home Administrator acknowledged that the MDS assessments should have been completed on paper during the downtime. The facility's failure to address this gap in their emergency preparedness plan contributed to the delay in completing the MDS assessments for R18 and R21, as well as approximately 30 other assessments from May and June.
Penalty
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A resident with multiple comorbidities, including DM, peripheral vascular disease, a right BKA, a stage 4 pressure ulcer, and a PICC line for IV therapy, was admitted and had detailed nursing notes and a comprehensive care plan initiated, but the admission MDS assessment was not completed within the required 14-day timeframe and did not trigger any CAAs. The facility’s Resident Matrix did not reflect the resident’s IV therapy because it relied on the incomplete MDS. The MDS nurse acknowledged being behind on assessments, and leadership confirmed that MDS coordinators were responsible for timely comprehensive assessments per facility policy, but there was no active monitoring process in place to ensure completion.
A resident’s admission MDS assessment was not completed within the required 14-day timeframe. Surveyors found that the admission MDS, dated with the resident’s admission date, remained incomplete upon record review. In an interview, the DON acknowledged that the admission assessment should have been completed. Facility policy titled “Guidelines for Assessments,” provided by an RN, requires that comprehensive admission MDS assessments be completed no later than the 14th calendar day after admission, but this standard was not met, resulting in a cited deficiency.
The facility failed to complete required annual MDS assessments within 14 days of the ARD for two residents. Record review showed that each resident had an annual MDS with an ARD that remained in progress and was not completed. Two MDS Coordinators, who shared responsibility for transmitting MDS assessments, acknowledged the assessments were incomplete due to transitioning from previous job duties. In interviews, the DON and the Administrator both stated they were aware that some MDS assessments were behind or past due, while also stating their expectation that MDS assessments be completed timely to meet federal regulations.
A resident with bradycardia, epilepsy, and vascular dementia did not receive a required annual comprehensive MDS assessment within the regulatory timeframe. Facility policy required a comprehensive assessment to be completed within a specified ARD window, but the last full comprehensive MDS for this resident was done more than a year before surveyor review. Staff interviews confirmed that the prior MDS coordinator failed to complete the assessment, despite an established process that uses an entry tracking assessment, payor-source–driven scheduling, and an MDS Clinical List to identify due assessments.
Surveyors found that admission MDS assessments were not completed within the required 14-day timeframe for two residents. Record review showed that each resident’s admission MDS was finalized several weeks after admission, and an interview with the MDS Coordinator confirmed that staff did not complete these admission assessments on time.
Surveyors found that the facility failed to complete required Care Area Assessments (CAAs) for four residents whose annual MDS assessments triggered multiple areas, including ADL functional/rehab potential, cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, mood, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, physical restraints, psychotropic drug use, and pain. An administrative nurse acknowledged that these CAAs were missed and stated she was still learning how to complete MDS assessments, despite a facility policy committing to accurate, timely, and complete MDS assessments.
Failure to Complete Timely Comprehensive Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive admission MDS assessment within 14 days of admission for one resident. Record review showed that this resident, a male with multiple diagnoses including a non-pressure chronic ulcer of the left heel, DM type 2, hyperlipidemia, insomnia, cellulitis of the left lower limb, peripheral vascular disease, a right below-knee amputation, and hypothyroidism, was admitted on a specified date. His admission MDS assessment, dated later in the month, showed no evidence that it was completed and no Care Area Assessments (CAAs) were triggered, despite the facility’s policy requiring a comprehensive assessment within 14 days of admission. Nursing documentation from the admission date described the resident as having a PICC line in the right upper arm, bowel and bladder incontinence, a right below-knee amputation, requiring two-person assistance with bed mobility and toileting, a mechanical lift for transfers, one-person assistance with dressing, hygiene, and bathing, supervision with eating and drinking, and the use of upper and lower dentures. The care plan initiated on the admission date included care areas and interventions for evidence-based practice, peripheral vascular disease, DM, incontinence, osteomyelitis, IV access, ADL self-care deficit, oral/dental health problems, and pressure ulcer care. A facility Resident Matrix later listed the resident as having a stage 4 pressure ulcer and being admitted on the same date, but did not reflect that he was receiving IV therapy, and there was no evidence in that document that he was receiving medication for diabetes, had an infection, or was on IV therapy. During observations and interviews, the resident was seen in bed with an IV pole, an IV access site in the right upper arm with an intact dressing, and a wound vac on the left heel with an intact dressing. He reported receiving IV medication for infection and care for his IV access and wound vac. The DON stated that the resident was on IV therapy and that the Matrix did not list IV therapy because it pulled from the MDS, which had not triggered IV therapy due to the incomplete assessment. The MDS Coordinator responsible for the admission assessment acknowledged that it had not been completed because she was behind on assessments and stated that the admission MDS should have been completed by a specific date. Facility leadership interviews confirmed that MDS Coordinators were responsible for completing comprehensive assessments, that there was no active monitoring process by the DON for timely completion, and that the facility policy required comprehensive assessments within 14 days of admission, with results used to develop, review, and revise the comprehensive plan of care.
Failure to Complete Admission MDS Assessment Within Required 14-Day Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete a required admission Minimum Data Set (MDS) assessment within the mandated timeframe for one resident. Record review on 3/19/26 at 11:20 A.M. showed that Resident C’s admission MDS assessment, dated with the resident’s admission date, was incomplete, despite the resident having been admitted on that same date. During an interview on 3/20/26 at 1:35 P.M., the DON stated that Resident C’s admission assessment should have been completed. The facility’s policy, “Guidelines for Assessments,” dated 5/29/24 and provided by RN 4 on 3/20/26 at 10:37 A.M., specifies that comprehensive admission MDS assessments must be completed no later than the 14th calendar day of the resident’s admission. The surveyors determined that this requirement was not met for Resident C, resulting in noncompliance with 410 IAC 16.2-3.1-31(d)(1). This citation relates to intakes 2803022 and 2799537.
Failure to Complete Annual MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete required annual Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for two residents. Record review showed that one resident, admitted on an unspecified date, had an annual MDS with an ARD of 2/6/26 that remained in progress and was not completed. Another resident, also admitted on an unspecified date, had an annual MDS with an ARD of 1/28/26 that likewise remained in progress and was not completed. During interviews, two MDS Coordinators stated they were both responsible for transmitting MDS assessments and acknowledged that the assessments for these residents were incomplete, attributing this 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, while stating their expectation that MDS assessments be completed timely to meet federal regulations. These findings demonstrate that the facility did not assess residents completely in a timely manner upon admission and periodically at least every 12 months, as required, because the annual MDS assessments for the two residents were not completed within the regulatory timeframe following the ARD.
Failure to Complete Required Annual Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a timely comprehensive Minimum Data Set (MDS) assessment for one resident, resulting in noncompliance with required assessment timeframes. Facility policy titled "MDS 3.0 Completion" stated that an annual comprehensive assessment must be completed using an Assessment Reference Date (ARD) no more than 366 days from the most recent prior comprehensive assessment and no more than 92 days from the most recent quarterly assessment. The resident’s electronic medical record showed an admission date of 02/18/2024 with diagnoses including bradycardia, epilepsy, and vascular dementia. Record review revealed that the last full comprehensive MDS assessment for this resident was completed on 01/24/2025, and no subsequent comprehensive assessment was completed within the required annual timeframe. During interviews, the MDS Coordinator II confirmed that a comprehensive assessment was not completed for this resident in February 2026, as required, and attributed the missed assessment to the previous MDS Coordinator’s failure to complete it. The Administrator stated that the MDS department should follow the Resident Assessment Instrument (RAI) Manual for guidance. The MDS Coordinator II further explained that the facility’s system for ensuring timely assessments involves completing an entry tracking assessment upon admission and then scheduling further MDS assessments based on the resident’s payor source, using the MDS Clinical List and the MDS tab to identify which assessment is due and when. Despite this system, the required annual comprehensive MDS assessment for this resident was not completed within the regulatory timeframe.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Minimum Data Set (MDS) admission assessments within 14 calendar days of admission for two residents. Record review showed that one resident was admitted on an unspecified date, but the admission MDS assessment for this resident was not completed until 02/04/26. Another resident was also admitted on an unspecified date, and the admission MDS assessment for this resident was not completed until 01/28/26. During an interview on 03/12/26 at 1:55 PM, the MDS Coordinator confirmed that staff did not complete the admission MDS assessments for these two residents within the required 14-day timeframe. The report states that this deficient practice could likely result in residents’ needs not being met, and it was identified through record review of admission records and MDS assessments, as well as staff interview. No additional medical history or clinical condition details for the residents are provided in the report.
Failure to Complete Required CAAs for Multiple Residents’ Annual MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete required Care Area Assessments (CAAs) for multiple residents whose comprehensive Minimum Data Set (MDS) assessments triggered these areas. The facility had a census of 29 residents with 12 residents sampled, and record review showed that four residents’ annual MDS assessments had triggered multiple CAAs that were not completed. One resident’s annual MDS dated 09/28/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, and psychotropic drug use, but none of these CAAs were completed. Another resident’s annual MDS dated 10/07/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, falls, pressure ulcer/injury, psychotropic drug use, and pain, which were also not completed. A third resident’s annual MDS dated 08/25/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, nutritional status, pressure ulcer/injury, physical restraints, and pain, but these CAAs were not completed. A fourth resident’s annual MDS dated 04/16/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, mood state, falls, nutritional status, dental care, pressure ulcer/injury, psychotropic drug use, and pain, and these CAAs were likewise not completed. During an interview on 03/10/26 at 4:06 PM, an administrative nurse acknowledged that the CAAs for these residents were missed, stated that the CAAs should be filled out to more accurately trigger care plan interventions, and noted she was still learning how to complete MDS assessments. The facility’s undated MDS Accuracy Audits policy documented a commitment to ensuring the accuracy, timeliness, and completeness of all MDS assessments.
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