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:
The facility failed to complete required MDS assessments within the required timeframe for 11 of 11 sampled residents. EHR review showed quarterly, annual, and discharge MDSs were completed well after the ARD, and the RN/MDS Coordinator stated remote corporate staff controlled the MDS schedule. The Administrator stated MDS were expected to be completed timely and accurately.
The facility failed to complete required quarterly MDS reviews for two residents. One resident had vascular dementia with behavioral disturbance, depression, dysphasia, dehydration, and a history of falls, and the other had dementia, a ruptured aneurysm with subarachnoid hemorrhage, cardiomyopathy, CHF, and chronic hip pain after a total hip replacement. Both residents’ most recent MDSs were annual reviews, and the quarterly assessments were overdue beyond the 92-day timeframe. The DCS confirmed the quarterly assessments were due but not completed.
Late Quarterly MDS Assessment: A resident’s quarterly MDS was not completed within the required 14-day window after the ARD. The MDS Coordinator confirmed the delay was an oversight, and the Administrator stated quarterly assessments are expected to be completed and submitted within regulatory timeframes.
Delayed Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required timeframe for multiple residents. Several quarterly assessments were signed well after the ARD, and multiple assessments were still marked in progress when reviewed. During interview, the MDS nurse acknowledged that the assessments should have been completed and signed earlier, and that in-progress assessments were not completed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required timeframe for four residents. One resident’s quarterly MDS had no completion date, while three others were completed well beyond the 14-day ARD window. The MDS Assessor said other duties interfered with timely completion, and the MDS Coordinator cited increased admissions and a change in the MDS submission system. The DON, former DON, and Administrator were aware of the late assessments.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure resident quarterly, admission, and discharge MDS assessments were completed within 14 days of the ARD for 11 of 11 sampled residents reviewed for resident assessments. Review of the RAI showed quarterly assessments and discharge assessments must be completed no later than the ARD plus 14 calendar days. EHR review showed multiple assessments were completed well beyond that timeframe, including an annual MDS for Resident 46 completed 39 days after the ARD, quarterly MDSs for Residents 55, 70, 99, 5, 118, 121, 128, 142, and 153 completed 34 to 40 days after the ARD, and a discharge MDS for Resident 73 completed 37 days after the ARD. During interview, the RN/MDS Coordinator stated remote corporate staff were doing the MDS and had control over the schedule. The Administrator stated the expectation was for MDS to be completed timely and accurately. The report identified the deficiency under WAC 388-97-1000(4)(a)(5)(d).
Missed Quarterly MDS Reviews for Two Residents
Penalty
Summary
The facility failed to ensure quarterly MDS review requirements were completed for 2 residents, Resident #6 and Resident #7, out of 5 residents reviewed. Record review showed Resident #6 was admitted with diagnoses including vascular dementia with behavioral disturbance, depression, dysphasia, dehydration, and a history of falls. The most recent MDS for Resident #6 was dated 11/29/25 and was an annual review, with the facility 75 days past the 92-day timeline for the next quarterly review assessment. Resident #7 was admitted with diagnoses including dementia, subarachnoid hemorrhage due to ruptured aneurysm, cardiomyopathy, congestive heart failure, and chronic hip pain after a total left hip replacement. The most recent MDS for Resident #7 was dated 11/26/25 and was an annual review, with the facility 78 days past the 92-day timeline for the next quarterly review assessment. During interview, the DCS stated the most current assessments for both residents were completed in 11/2025 and that their quarterly assessments were due in 2/2026, but were not completed. The facility policy stated quarterly assessments are to be completed no later than the ARD of the prior assessment plus 92 calendar days.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date for Resident #2. Resident #2 was admitted to the facility on [DATE], and the electronic medical record showed a quarterly MDS with an ARD of 04/03/26 that was marked completed on 04/20/26. During interview, the MDS Coordinator verified the quarterly assessment was not completed within the regulatory time frame and stated the late completion was an oversight. The Administrator also confirmed that quarterly assessments should be completed within 14 days of the ARD and stated it was her expectation that MDS assessments be completed and submitted within the required timeframes.
Delayed Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed at least every 92 days following the previous OBRA assessment for six of 19 sampled residents. Resident 71’s quarterly MDS had an ARD of 11/14/25 but was not signed complete until 12/17/25, and the MDS nurse stated it should have been completed and signed on 11/27/25. Resident 73’s quarterly MDS had an ARD of 8/28/25 and was signed complete on 10/30/25; the MDS nurse stated it should have been completed and signed on 9/11/25. Resident 94’s quarterly MDS with an ARD of 11/25/25 was signed complete on 12/15/25, and another quarterly MDS for the resident with an ARD of 2/25/25 was still in progress. Resident 111’s quarterly MDS with an ARD of 8/28/25 was signed complete on 10/30/25, and another quarterly MDS with an ARD of 2/19/26 was in progress. Resident 121’s quarterly MDS with an ARD of 8/27/25 was signed complete on 10/29/25, and another quarterly MDS with an ARD of 2/23/26 was in progress. Resident 16’s quarterly MDS with an ARD of 10/31/25 was signed complete on 1/12/26. The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual states that the quarterly assessment must be completed at least every 92 days following the previous OBRA assessment of any type, and that the MDS completion date must be no later than 14 days after the ARD. During interview and record review, the MDS nurse acknowledged that several of the quarterly assessments should have been completed and signed earlier than they were, and stated that assessments marked in progress were not completed.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents sampled from the resident assessment task. Resident #184 had a Quarterly MDS with an ARD of 02/06/2026 that was not completed and did not include a completion date in item Z0500B. Resident #35’s Quarterly MDS with the same ARD was not completed until 77 days after the ARD, Resident #25’s Quarterly MDS with an ARD of 01/21/2026 was not completed until 71 days after the ARD, and Resident #36’s Quarterly MDS with an ARD of 11/28/2025 was not completed until 22 days after the ARD. The facility policy titled Minimum Data Set (MDS 3.0) Completion stated that all MDS assessments are to be completed, signed, and transmitted in accordance with federal requirements and the RAI Manual, and that required assessments are to be scheduled based on the ARD and completed within 14 days. The CMS LTC Facility Resident Assessment Instrument 3.0 User’s Manual Version 1.20.1 also stated that the completion date for quarterly assessments must be no later than 14 days after the ARD. The report identified that these quarterly assessments were not completed within that required period. Resident #184 had diagnoses including dementia, hypertension, and hyperlipidemia, and the Quarterly MDS documented a BIMS score of 10, indicating moderately impaired cognition. Resident #35 had diagnoses including nontraumatic subarachnoid hemorrhage, dysphagia, and aphasia, and the Quarterly MDS noted the BIMS was not completed because the resident was unable to understand others. Resident #25 had diagnoses including multiple sclerosis, tremor, and ulcerative colitis, and the Quarterly MDS documented a BIMS score of 15, indicating intact cognition. During interviews, the MDS Assessor stated they were responsible for completing all MDS assessments and said they were unable to complete them on time because of other duties such as care plan meetings. The MDS Coordinator stated quarterly assessments should be completed within 14 days but reported delays related to a sudden influx of admissions and a change in the MDS submission system. The former DON, current DON, and Administrator were aware of the late completion of MDS assessments.
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