Delayed MDS Assessments Due to System Transition
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for six out of ten residents reviewed. 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 calendar days following admission, and an annual MDS assessment must be completed no later than the Assessment Reference Date (ARD) plus 14 calendar days. However, the review revealed that the MDS assessments for Residents R2, R91, R107, R132, R256, and R259 were not completed within these time frames. The delay in completing the MDS assessments was attributed to a transition in the facility's computer system, which was down for a week. Additionally, the Registered Nurse Assessment Coordinators (RNACs) were incorrectly set up in the new system, resulting in a lack of access to charting for two weeks. This led to the facility being approximately three weeks behind in completing the assessments. The Director of Nursing confirmed the failure to complete the assessments within the required time frame during an interview.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident admitted with encephalopathy did not have their admission MDS assessment completed within the required timeframe, as the assessment was finalized 15 days after entry instead of within the mandated 13 days. Staff interviews revealed a lack of clear policy and inconsistent knowledge regarding MDS assessment timing requirements.
Two residents' care plans were not updated to address identified needs and interventions related to sexual behavior and expression after an incident where both were found in bed together naked. One resident had severe cognitive impairment and a history of reaching out to others, while the other was cognitively intact with behavioral symptoms. The care plans did not include specific interventions for sexual behavior, despite facility policy requiring comprehensive, person-centered care planning.
A resident with chronic obstructive pulmonary disease and type 2 diabetes did not receive a required annual comprehensive MDS assessment within the mandated timeframe. Review and staff interview confirmed the assessment was overdue, contrary to facility policy requiring annual completion.
A resident with multiple chronic conditions received additional daily hydration via PEG tube as ordered, but the facility failed to accurately code this intake in the MDS Nutritional Status section. The MDS assessments did not reflect the resident's average fluid intake by tube feeding, despite clear documentation in the MAR and confirmation by the dietician.
A resident admitted with multiple fractures, encephalopathy, hallucinations, and alcohol withdrawal did not receive a nursing admission assessment as required. Review of the medical record confirmed the assessment was missing, and facility leadership verified this omission. No policy regarding nursing assessment timing was available.
The facility failed to complete timely comprehensive admission assessments for two residents. One resident, with multiple diagnoses including pressure-induced deep tissue damage, was readmitted but not assessed until two days later, and the assessment remained incomplete. Another resident, with serious health conditions, was readmitted without any readmission or wound assessments conducted. These deficiencies were identified during a complaint investigation.
Untimely Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) admission assessment within the required timeframe for one resident. Specifically, a resident admitted with a diagnosis of encephalopathy had an MDS admission assessment completed 15 days after the entry date, exceeding the regulatory requirement that the assessment be completed no later than 13 days after admission. The resident's admission date and the corresponding MDS documentation were reviewed, confirming the late completion. Interviews with facility staff revealed a lack of clear policy regarding the timing of MDS assessments. The MDS Coordinator stated she relied on the Resident Assessment Instrument (RAI) manual for guidance but acknowledged the assessment was not completed within the required period. The Assistant Director of Health Services was unfamiliar with the completion date requirements, and the Executive Director indicated that staff should refer to the RAI manual for timing but did not provide further direction.
Failure to Update Care Plans for Sexual Behavior/Expression
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were updated to address identified resident needs and appropriate interventions, specifically regarding sexual behavior and expression. For one resident with severe cognitive impairment due to dementia, the care plan noted a tendency to reach out to people to hold and kiss hands and faces, but did not include any further interventions or information addressing sexual behavior or expression, despite an incident where the resident was found in bed naked with another resident. The care plan was not updated to reflect the behaviors identified during the facility's self-reported incident investigation. Similarly, another resident, who was cognitively intact and had a history of chronic medical conditions and behavioral symptoms such as verbal aggression and inappropriate sexual comments, had a care plan that only included redirection for inappropriate sexual comments. The care plan lacked additional interventions or information related to sexual behavior or expression, even after the incident involving both residents was investigated. The facility's policy required comprehensive care plans to be developed and updated based on resident needs, but this was not followed in these cases.
Failure to Complete Timely Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for one resident within the required timeframe of 366 days from the previous assessment. Record review showed that the resident, who had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes mellitus, was admitted on a specified date and did not have a comprehensive MDS assessment completed after the last one documented. This was confirmed during an interview with the MDS Coordinator, who acknowledged that the required assessment had not been completed within the mandated period. Facility policy requires that comprehensive assessments be conducted according to the Resident Assessment Instrument (RAI) User Manual, with annual assessments completed at least every 366 days.
Plan Of Correction
Resident #22 was immediately assessed and found to have no adverse effects. All residents have the ability to be affected. MDS reviewed all residents for open annual MDS Assessments on 5/22/25 to ensure they were complete. Resident #22 annual MDS Assessments were immediately reviewed and completed on 5/29/25 by MDS. Admin immediately provided MDS Coordinator education on MDS Assessments policy and timely submission. DON/designee to audit 2 residents with annual MDS assessments due weekly for 4 weeks. Results to be reviewed in QAPI.
Failure to Accurately Complete MDS Nutritional Status for Resident Receiving PEG Tube Hydration
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Nutritional Status section for a resident who was receiving additional fluid intake via a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had multiple diagnoses including paranoid schizophrenia, type 2 diabetes, major depression, personality disorder, hypertension, and osteomyelitis of the vertebra, was admitted and re-admitted to the facility and had physician orders for specific water flushes through the PEG tube for hydration and tube patency. Medical record reviews showed that the resident consistently received 200 ml to 400 ml of additional water per day via the PEG tube, as documented in the Medication Administration Record (MAR) over several months. Despite this, the quarterly MDS assessments did not reflect the resident's daily additional hydration in Section K (Swallowing/Nutrition Status), which is required to document the average fluid intake per day by tube feeding. The dietician confirmed that Section K was not coded to show the percentage of additional water intake the resident was receiving per PEG tube, even though the Resident Assessment Instrument (RAI) Manual specifies the method for calculating and coding this information. This omission resulted in inaccurate completion of the MDS for the resident's nutritional status.
Failure to Complete Nursing Admission Assessment
Penalty
Summary
The facility failed to complete a nursing assessment upon admission for one resident who was admitted with multiple medical conditions, including multiple rib fractures, encephalopathy, hallucinations, and alcohol withdrawal. Review of the resident's electronic and paper medical records showed that no nursing admission assessment was performed at the time of arrival. This was confirmed during an interview with the Chief Operating Officer, who acknowledged the absence of the required assessment. Additionally, the facility was unable to provide a policy regarding nursing assessments and their required timing.
Failure to Complete Timely Admission Assessments for Two Residents
Penalty
Summary
The facility failed to complete comprehensive admission assessments in a timely manner for two residents, which was identified during a complaint investigation. Resident #43 was readmitted to the facility with multiple diagnoses, including pressure-induced deep tissue damage of the sacral region. Despite being readmitted on 02/05/25, the comprehensive readmission assessment was not initiated until 02/07/25 and was still incomplete at the time of review. This delay was confirmed by an interview with the Regional Nurse. Similarly, Resident #49, who was readmitted with a range of serious health conditions including cerebrovascular accident with right-sided hemiplegia and severe protein-calorie malnutrition, did not have a readmission assessment completed. The resident was readmitted on 02/11/25, but as of 02/13/25, the Director of Nursing confirmed that no readmission assessment or wound assessments had been conducted. This deficiency was noted as an incidental finding during the investigation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
