Failure to Complete MDS Assessments Timely
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed within the required time frame for six out of 24 residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following a resident's admission. However, several residents had their MDS assessments completed beyond this timeframe, with some not completed at all by the time of the survey. Specifically, Resident R67, R147, R148, R153, R248, and R249 were affected, with completion dates ranging from January 5, 2025, to January 13, 2025, or not completed at all by January 13, 2025. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), Employee E9, who acknowledged the failure to complete the assessments timely.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws. A comprehensive Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next annual MDS assessment or admission MDS assessment for the in-house residents. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting comprehensive assessments by the Regional Clinical Reimbursement Specialist or a designee. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' annual and admission MDS assessments to ensure compliance with F636 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete MDS CAAs for Two Residents: The facility failed to complete triggered CAAs for two residents. One resident’s Activity CAA and another resident’s Nutritional Status CAA were triggered on Significant Change MDS assessments but lacked an analysis of findings. An ADON confirmed the missing analysis, and an RN stated triggered CAAs were expected to include analysis.
Late Completion of Annual MDS Assessment: A resident's annual MDS assessment was completed after the required timeframe. The MDS Coordinator said she became overwhelmed by multiple new admissions, and the Regional MDS Consultant confirmed the assessment was late after the facility identified coding and completion issues through a scrubber report. The Administrator stated MDS assessments were expected to be completed and submitted within regulatory timeframes.
Incomplete Annual MDS Assessment: A resident’s annual MDS was incomplete because cognition and mood were not assessed. The record showed no BIMS score and no assessment of memory, recall, or daily decision-making skills, and the mood section was also left blank. The issue was identified during review of an incident in which the resident alleged money had been stolen from a wallet, and the MDS Coordinator stated the sections were assigned to social work but the assessment window was missed due to staffing issues.
A resident's admission MDS was completed after the required timeframe. The RN MDS Coordinator confirmed the assessment was not completed on time.
Late Completion of Comprehensive MDS Assessments: The facility failed to complete required comprehensive MDS assessments and related CAA processes within the required time frames for multiple residents. Review of records showed several assessments were completed one to six days late, and the NHA confirmed the late completions during interview.
Failure to Complete CAA Analysis for Comprehensive MDS Assessments: The facility did not complete required CAA analyses for multiple residents after comprehensive MDS assessments triggered care areas such as cognition, communication, urinary incontinence, falls, nutrition, pressure injuries, pain, and psychotropic drug use. The Admin Nurse stated the facility used the RAI Manual for MDS/CAA guidance and acknowledged the CAA documentation lacked source documentation and individualized analysis for the triggered areas.
Incomplete MDS CAAs for Two Residents
Penalty
Summary
The facility failed to complete comprehensive MDS assessments for two residents. For R67, the EMR showed a Significant Change MDS dated [DATE], and the Activity CAA dated 06/05/26 was triggered but lacked an analysis of findings. For R10, the EMR showed a Significant Change MDS dated 05/01/2026, and the Nutritional Status CAA dated 05/06/2026 was triggered but also lacked an analysis of findings. On 08/05/26 at 11:15 AM, Administrative Nurse D confirmed that the Activity CAA for R67 was triggered but did not include an analysis of findings. On 08/04/26 at 11:30 AM, Administrative Nurse E stated that triggered CAAs were expected to include an analysis of findings and confirmed that the Nutritional Status CAA for R10 lacked analysis. The facility policy for MDS, revised 09/29/25, stated that residents are assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan.
Late Completion of Annual MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive MDS assessment within 14 calendar days of the ARD for one resident. Resident #13 was admitted to the facility and had an annual MDS assessment dated [DATE] that was marked completed on 06/03/26, although it should have been completed by 05/20/26. The assessment was therefore completed 14 days late. During interviews, the MDS Coordinator stated she had been in her position since 10/05/25 and said she became overwhelmed with completing MDS assessments because the facility had many new admissions at the time the assessment was due. She verified that Resident #13's MDS was not completed within the regulatory timeframe. The Regional MDS Consultant stated the facility had identified inaccuracies in coding and late MDS completion through a scrubber report and had placed a performance improvement plan into effect, and he confirmed Resident #13's annual MDS assessment was completed late. The Administrator stated it was his expectation that MDS assessments be completed and submitted within regulatory timeframes.
Incomplete Annual MDS Assessment
Penalty
Summary
The facility failed to complete a complete and accurate annual assessment for Resident #7 by not assessing cognition, mood, and behavior on the resident’s annual MDS. The annual MDS had an assessment reference date of 6/3/26, but Section C, Cognitive Patterns, was not assessed. There was no BIMS summary score, and the resident’s short-term and long-term memory, memory/recall ability, and cognitive skills for daily decision making were not assessed. Section D, Mood, was also not assessed. The deficiency was identified during review of facility reported incident 3094393 and the resident’s medical record on 7/29/26. The incident report stated that Resident #7 alleged money had been stolen from the resident’s wallet and initially reported the concern to a GNA on 7/3/26, stating the money had been stolen sometime over the prior month. During interview on 7/30/26, the MDS Coordinator stated that social work was responsible for completing Sections C and D and that the assessment time period had been missed because of staffing issues in the department.
Late Completion of Admission MDS
Penalty
Summary
The facility failed to complete a comprehensive admission assessment within the required timeframe for Resident 128. Resident 128 was admitted to the facility on [DATE], and the admission MDS was completed on 7/22/26, five days after the regulatory timeframe. On 7/22/26 at 12:06 PM, Staff 7, the RN MDS Coordinator, confirmed that Resident 128's admission MDS was not completed within the regulatory timeframe.
Late Completion of Comprehensive MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments and the associated Care Area Assessment process were completed within the required time frames for 16 of 87 residents reviewed. The report cites the RAI User’s Manual requirement that admission MDS assessments and CAA completion be finished no later than the admission date plus 13 calendar days, and that an MDS assessment be completed every 92 days. Review of the CMS MDS validation report and clinical records showed that multiple residents had comprehensive assessments completed after the required deadline, including residents whose ARDs ranged from May through July 2026 and whose assessments were completed one to six days late. Specific examples included residents 9, 57, 83, 97, 98, 129, 152, 153, 157, 159, 162, 163, 165, 170, 171, and 172, with late completion documented for each. The Nursing Home Administrator confirmed in interview on July 23, 2026, at 11:15 a.m. that the comprehensive MDS assessments were not completed in the required time frames. The deficiency was cited under 28 Pa. Code 211.5(f), Clinical records.
Failure to Complete CAA Analysis for Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis for multiple residents after comprehensive MDS assessments were completed. Review of the most recent comprehensive MDS documentation for R2, R9, R12, R21, R29, R33, and R38 showed that triggered CAAs were not completed for multiple care areas, including cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, psychosocial well-being, nutritional status, pressure ulcer/injury, psychotropic drug use, functional abilities, falls, behavioral symptoms, pain, dehydration/fluid maintenance, dental care, and visual function, depending on the resident. On 07/22/2026, the Administrative Nurse stated the facility used the RAI Manual for guidance in completing MDSs and CAAs for comprehensive assessments and reported she was not aware that CAA completion should include the location of the information and resource materials used to support the individualized analysis for triggered areas until training on 04/26/2026. She verified that the CAA documentation for the named residents lacked source documentation showing analysis of the collected data, other than narrative identifying where the triggering data was located, and lacked the analysis described in the RAI Manual.
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