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:
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.
Failure to Document Required Abuse Risk Assessments: The facility did not document required abuse risk assessments for three residents reviewed for abuse or misappropriation of property. Instead, staff presented trauma screening forms and stated they used the trauma screen as the abuse risk assessment, even though the form excluded abuse risk and the Social Services staff said abuse risk assessments should be completed quarterly for each resident. The residents had psychiatric diagnoses including bipolar disorder, schizoaffective disorder, and paranoid schizophrenia.
Quarterly MDS assessment was not completed within the required 3-month timeframe for a resident with DM2, dysphagia, and bilateral carotid artery stenosis. The RNAC said there was no RN available to sign the MDS because the DON had resigned, and the assessment remained overdue in the EHR despite the facility policy requiring quarterly updates per the RAI manual.
Late Quarterly MDS Assessments for Five Residents: The facility failed to complete quarterly MDS assessments on time for five residents. Residents with diagnoses including schizophrenia, bipolar disorder, dementia, DM, metabolic encephalopathy, and mobility impairment had assessments showing cognitive impairment and assistance needs, but the MDS nurse confirmed the quarterly reviews were overdue or not completed. The MDS nurse, DON, and ADMIN stated MDSs must be completed timely to reflect current status and support care planning.
Late and Missing Quarterly MDS Assessments: The facility failed to complete and submit quarterly MDS assessments on time for multiple residents, including residents with diagnoses such as HTN, DM2, depression, anxiety, osteoporosis, CHF, ESRD, and cerebral palsy. EMR review showed several assessments remained unsubmitted or were marked late, and the DON confirmed the quarterly MDSs were not completed timely after staffing changes left the facility without someone completing the assessments.
Missed Quarterly MDS and Elopement Assessments: A resident with dementia, anxiety, and psychotic disorder had no quarterly MDS completed within the required timeframe after the last assessment, and an elopement assessment was not completed when exit-seeking behavior was documented. The care plan identified wandering, elopement risk, exit-seeking behavior, and fall risk, while the DON, Administrator, and MDS nurses confirmed the quarterly assessments were due and that one was missed.
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."
Failure to Document Required Abuse Risk Assessments
Penalty
Summary
The facility failed to ensure trauma screenings were documented as recommended and failed to conduct or document required abuse risk assessments for three residents reviewed for abuse or misappropriation of property. The residents had diagnoses including bipolar disorder and unspecified psychosis, schizoaffective disorders, and paranoid schizophrenia. One resident also had a facility concern form dated 5/2/26 stating the resident misplaced $40. On 6/23/26, the surveyor reviewed the EMR and found no documented abuse risk assessments for the three residents. On 6/24/26, the ADON presented trauma screening forms for the three residents instead of abuse risk assessments and stated the facility uses the trauma screen for the abuse risk assessment. The trauma screening form stated it measures risk for psychiatric, behavioral, and/or physical symptomatology related to trauma and excludes risk for abuse. The Social Services staff stated that abuse risk assessments should be done for each resident and that they are required quarterly, but also stated they did not believe the facility had that specific assessment form. The ADON further stated the facility did not have a policy for abuse risk assessments, while the revised policy described a trauma screening process used to identify residents with a history of mistreatment or greater than normal risk for mistreatment.
Quarterly MDS Assessment Not Completed on Time
Penalty
Summary
The facility failed to complete a resident’s quarterly MDS assessment within three months of the most recent comprehensive assessment. Record review for Resident #35 showed an admission record with diagnoses including Type 2 Diabetes Mellitus, dysphagia, and occlusion and stenosis of bilateral carotid arteries. The resident’s previous quarterly MDS was completed, signed, and uploaded on 02/05/2026, and the current quarterly MDS was due by 06/05/2026, but the record review showed it was not completed, signed, or uploaded. The electronic health record under the MDS tab did not show a more recent assessment submitted since 02/05/2026, and PCC showed the quarterly assessment was 12 days overdue. During interview, the RNAC stated there was not an RN on staff who could sign the MDS assessments because the DON had resigned, and she was waiting for it to be signed. The RNAC stated she knew the three-month guideline and would have the assessment signed as soon as possible. The ADMIN stated she does not really get into clinical because that is not her specialty, but the company would hold staff to the highest standards per guidelines. The facility policy stated that assessments should be updated and reviewed at least quarterly as defined in the RAI manual.
Late Quarterly MDS Assessments for Five Residents
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed and transmitted within the required OBRA time frame for five sampled residents. For Residents 21, 34, and 123, the quarterly MDS assessments were not completed within the mandated 92-day schedule. For Residents 12 and 88, the quarterly MDS assessments were also late and were still in process when reviewed by the MDS nurse. Resident 21 was admitted with diagnoses including paranoid schizophrenia, DM, and extrapyramidal disorder. The H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed severely impaired cognitive skills for daily decision making and need for assistance with eating, hygiene, showering, dressing, bed mobility, and transfers. During interview and record review, the MDS nurse stated the resident’s last MDS was completed and transmitted on 2/12/2026 and no MDS had been completed after that; the quarterly assessment due 5/4/2026 was not completed. Resident 34 was admitted with bipolar disorder, schizophrenia, and blindness of the left eye. The H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed moderately impaired cognitive skills for daily decision making and need for assistance with eating, hygiene, dressing, showering, bed mobility, and transfers. The MDS nurse stated the last MDS was completed and transmitted on 2/10/2026 and no MDS had been completed after that; the quarterly assessment due 4/30/2026 was not completed. Resident 123 was admitted with dementia, DM, and schizophrenia. The H&P stated the resident could make needs known but could not make medical decisions. The MDS showed severely impaired cognitive skills for daily decision making and need for assistance with showering, personal hygiene, eating, oral hygiene, toileting hygiene, dressing, bed mobility, and transfers. The MDS nurse stated the last MDS was completed and transmitted on 2/12/2026 and no MDS had been completed after that. Resident 12 had diagnoses including metabolic encephalopathy and muscle wasting and atrophy, and the MDS showed severe cognitive impairment with assistance needs for eating, transfers, bathing, dressing, oral hygiene, and bed mobility. The MDS nurse stated the last MDS was completed on 2/2/2026 and the quarterly MDS due 5/2/2026 was late. Resident 88 had diagnoses including difficulty walking and paranoid schizophrenia, and the MDS showed moderately impaired cognitive skills with assistance needs for eating, oral hygiene, dressing, and transfers. The MDS nurse stated the last MDS was completed on 2/12/2026 and the quarterly MDS due 5/14/2026 was late. The MDS nurse stated MDS assessments were required on admission, quarterly, annually, and with significant change in condition, and that timely completion was necessary so the information accurately reflected the resident’s current status. The administrator and DON stated MDS assessments should be completed timely because resident care and treatment are based on the resident’s current health status and the assessments support care planning. Facility policy stated OBRA-required assessments, including quarterly assessments, must be performed for all Medicare and/or Medicaid certified nursing home residents, and the resident assessment coordinator is responsible for ensuring timely assessments.
Late and Missing Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed on a quarterly basis and submitted within the required timeframe for 17 of 18 residents reviewed for resident assessments. Facility policy titled, Resident Assessment Instrument, stated the Assessment Coordinator was responsible for ensuring the Interdisciplinary Assessment Team conducted timely resident assessments and reviews at least quarterly. State Operations Manual guidance cited in the report stated a quarterly assessment is timely when the ARD is within 92 days of the previous OBRA assessment and the MDS completion date is no later than 14 days after the ARD. Record review showed multiple residents had quarterly MDS assessments that were overdue, not completed, or not submitted to CMS by the time of survey. Several residents had quarterly assessments with created dates of 05/15/2026 that remained incomplete and unsubmitted as of 06/10/2026, with EMR symbols showing a triangle/exclamation mark and no thumbs-up symbol to indicate CMS acceptance. Examples included residents with diagnoses such as hypertension, diabetes, depression, anxiety disorder, osteoporosis, heart failure, kidney failure, end stage renal disease, cerebral palsy, severe intellectual disability, and gastroesophageal reflux. For some residents, the most recent accepted assessment was an admission, quarterly, or significant change assessment completed months earlier, and the next quarterly assessment was due before the late or missing assessment was completed. The report also identified residents whose quarterly assessments were not completed after a significant change or after discharge. One resident had a significant change MDS as the most recent assessment, while another resident had been discharged and no discharge MDS was completed. During interview, the DON stated the EMR symbols indicated whether assessments were accepted by CMS or submitted late, and she confirmed the quarterly MDS assessments for the listed residents were not completed and submitted timely. She stated she had started catching up on overdue assessments after beginning employment because no one had been completing MDS assessments after the former DON left. The Administrator stated the facility had a lapse in completing MDS assessments because the person completing them left, and his expectation was for staff to follow policy and procedure.
Missed Quarterly MDS and Elopement Assessments
Penalty
Summary
The facility failed to ensure Resident #1’s quarterly MDS assessment was completed at least once every 3 months. Resident #1 was a [AGE]-year-old male with diagnoses including unspecified dementia, anxiety disorder, and psychotic disorder with delusions due to a known physiological condition. Review of the record showed the last quarterly MDS assessment was completed on 02/18/2026, and no other MDS assessments were completed for more than 3 months after that date. The record also showed Resident #1 had behaviors relevant to elopement risk. A progress note dated 04/21/2026 at 11:26 pm documented exit-seeking behavior. The care plan initiated on 04/22/2026 identified behavioral symptoms including wandering throughout the facility, elopement risk, exit-seeking behavior, and fall risk related to dementia. It also noted that the resident verbalized wanting to smoke and had documented wandering in the nurse’s station. Review of the elopement assessments showed one was completed on admission and another after the incident on 06/07/2026, but there was no elopement assessment completed when the resident exhibited exit-seeking behavior in April 2026 and no quarterly elopement assessment after the initial admission assessment. During interviews, the DON, Administrator, MDS Nurse A, and MDS Nurse B all stated quarterly MDS assessments and elopement assessments were expected, and MDS Nurse B acknowledged the quarterly MDS assessment due on 05/18/2026 was missed.
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