Failure to Complete Quarterly MDS Assessments on Time
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for 37 out of 79 residents reviewed. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual specifies that quarterly assessments must be completed within 14 days after the Assessment Reference Date (ARD), and these assessments are due every 92 days. However, the facility did not adhere to these guidelines, resulting in late completion of assessments for numerous residents. For instance, Resident 1 had an ARD of November 2, 2024, and the assessment was due by November 15, 2024, but it was completed 10 days late on November 25, 2024. Similarly, Resident 2 had two instances of late assessments, with one being seven days late and the other six days late. This pattern of delayed assessments was consistent across multiple residents, with delays ranging from two to eleven days past the required completion date. The Registered Nurse Assessment Coordinator (RNAC) and the Director of Nursing confirmed during an interview that the quarterly MDS assessments were not completed within the required timeframe. This deficiency was noted under the regulations 28 Pa. Code 211.5(f) Clinical Records and 28 Pa. Code 211.12(d)(5) Nursing Services, indicating a failure in maintaining timely and accurate clinical records as mandated by the state regulations.
Plan Of Correction
1. A quarterly Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. 2. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next quarterly 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. 3. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting quarterly assessments by the Regional Clinical Reimbursement Specialist or a designee. 4. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' quarterly MDS assessments to ensure compliance with F638 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. 5. 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:
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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