Incomplete RAI and CAA Documentation
Summary
The facility failed to ensure the Resident Assessment Instrument (RAI) and Care Area Assessments (CAA's) were completed with thorough summaries that analyzed the resident's needs, strengths, goals, and preferences for 4 of 6 residents reviewed for comprehensive assessments. The report states the RAI should include the MDS assessment, the CAA process, and utilization guidelines, and the facility policy required CAA documentation to include causes and contributing factors, the nature of the condition, complications, risk factors, factors considered in care planning, and any need for further evaluation by another healthcare provider. For Resident 33, admitted with chronic pain syndrome, the admission MDS triggered a pain CAA, but the MDS assessment dated 06/06/2025 showed the CAA did not contain comprehensive summaries or analysis of current goals, preferences, strengths, or needs. For Resident 98, admitted with spinal stenosis, bilateral foot drop, and lymphedema, the admission MDS dated 08/01/2025 triggered a pain CAA, but the pain CAA was blank except for one line stating the resident complained of pain during interview. Staff R, RN MDS Nurse, stated the CAA's should address anything triggered and confirmed the pain CAA's did not address all issues, including pain medications and possible adverse side effects. For Resident 4, readmitted with right hemiplegia and hemiparesis following cerebrovascular disease, the annual MDS showed the Functional Abilities (Self-care and Mobility) CAA was blank, and other triggered CAAs including communication, urinary incontinence and indwelling catheter, nutritional status, dehydration and fluid maintenance, dental care, and pressure ulcer/injury did not contain comprehensive assessments. For Resident 3, admitted with broken or loose teeth, the admission nursing collection tool and MDS documented broken teeth, inflamed or bleeding gums, loose natural teeth, and mouth or facial pain, but the Dental Care CAA was blank; other triggered CAAs also lacked comprehensive assessments. Resident 3 was observed with broken upper front teeth, missing upper and lower back teeth, and loose lower front teeth, and Staff R stated the CAAs were supposed to include analysis of findings, dental assessment, oral care, assistance level, and referral if needed. Staff B, DON, stated they expected the MDS assessment and CAA to be complete and accurate. This was identified as a repeat deficiency from the prior SOD dated 11/15/2024.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete MDS Mood and Behavior Assessments: A resident with a BKA, HF, and hypothyroidism had annual and quarterly MDS assessments that left Sections D and E as not assessed/no information, despite care plan documentation of depressed mood, little interest in activities, refusal of meds, weights, and cares, and limited engagement noted during survey observations. Nursing notes also showed refusals of VS and meds, while the SW said she had not spoken with the resident and the MDS Coordinator could not verify the accuracy of the completed sections.
Delayed Admission MDS Completion: A resident admitted with kidney failure and a bladder infection had an admission MDS still in process nearly a month after admission, with multiple sections unanswered. The MDS/RN and DON both stated the admission MDS should have been completed within the required 14-day timeframe.
Incomplete MDS assessments and missing coding for oxygen and alarms. A resident admitted with multiple rib fractures had an incomplete admission MDS, and two residents receiving continuous O2 for COPD or chronic respiratory failure were not coded as receiving oxygen on their MDSs despite MAR documentation. In addition, six residents with dementia, Alzheimer's disease, falls, gait issues, or weakness had active bed, chair, floor, bathroom door, or wheelchair alarm orders, but their MDS assessments did not reflect alarm use.
The facility failed to complete an admission assessment for a resident after the resident returned from the hospital. Records showed the resident was discharged, later came back to the facility, and no comprehensive assessment was completed for the readmission. An MDS coordinator stated the resident should have had an admission assessment completed.
A facility failed to accurately complete MDS assessments for two residents. One resident with major depressive disorder was receiving sertraline, but the antidepressant was not documented on the MDS, so the psychotropic CAA was not triggered and the admission CAA/care plan did not reflect it. Another resident with insomnia and major depressive disorder was receiving zolpidem, but the hypnotic was not documented on the MDS; the psychotropic CAA did not include the hypnotic or insomnia, and the care plan was not updated with psychotropic use documentation.
A resident with paraplegia and intact cognition used a transfer pole in bed for turning and during care, but the OT/PT evals and later rehab screen did not document the pole’s use, benefit, clinical justification, or appropriateness. The care plan identified the transfer pole, yet the restorative nursing order focused only on lower-extremity PROM, and the DOR, MDS Coordinator, and DON acknowledged the missing assessment and documentation.
Incomplete MDS Mood and Behavior Assessments
Penalty
Summary
The facility failed to complete all required sections of the Resident Assessment Instrument 3.0 Minimum Data Set for one resident, specifically Sections D (Mood) and E (Behavior), on both an annual comprehensive assessment and a quarterly assessment. Both assessments were documented as “Not assessed/no information,” even though the resident’s record contained information about mood concerns, refusal behaviors, and resident preferences that should have been reflected in the assessment. Resident #33 was admitted with diagnoses including a below-the-knee right leg amputation, heart failure, and hypothyroidism. The resident’s care plan, dated 3/9/26, identified potential depressed mood, impaired psychosocial well-being with little interest or pleasure in doing things, and impaired behavior related to refusal of cares to reduce skin breakdown risk, refusal of medications, refusal of weights, and refusal to get out of bed. The continuity of care document also included a goal for the resident to show a decrease in behavior episodes by the next review date. Surveyors observed the resident lying in bed in a hospital gown with flat facial expressions and limited engagement in conversation, and random observations showed the resident remained in bed, slept, and had minimal interactions with staff. Nursing notes documented refusal of vital signs and refusal of medications, with the provider notified of frequent medication refusal. During interviews, the MDS Coordinator stated the Social Worker completed Sections C, D, E, and Q, but she could not verify the accuracy of those sections, and the Social Worker stated she had not spoken with the resident and that the assessment dates may have been missed.
Delayed Admission MDS Completion
Penalty
Summary
The facility failed to timely complete the admission minimum data set (MDS) assessment within 14 days of admission for Resident 114. The resident was admitted with diagnoses of kidney failure and bladder infection and was able to make needs known. Review of the electronic health record on 05/19/2026 showed the admission comprehensive MDS was still in process 29 days after admission, with multiple sections unanswered. During interviews, the MDS/RN stated the admission MDS should have been completed within 14 days but was not, and the DNS stated it was their expectation that the MDS be completed per schedule and that Resident 114 should have had the admission MDS completed within 14 days of admission.
Incomplete MDS Assessments and Missing Oxygen and Alarm Coding
Penalty
Summary
The facility failed to complete a comprehensive and accurate MDS assessment for a resident admitted with multiple rib fractures. The admission MDS assessment was documented as incomplete as of 5/20/2026, and the MDS Coordinator was unable to provide evidence that the admission assessment was completed within 14 days as required. The facility also failed to accurately code oxygen therapy on the MDS for 2 residents who were receiving continuous oxygen. One resident, admitted with COPD and dependence on supplemental oxygen, had an order for continuous oxygen at 3-4 liters via nasal cannula every shift, and the MAR documented oxygen administration continuously from 4/1 through 5/20/2026. Another resident, admitted with chronic respiratory failure with hypoxia, had orders for continuous oxygen at 2-4 liters via nasal cannula every shift, and the May MAR documented oxygen administration continuously from 5/1 through 5/20/2026. In both cases, the MDS assessments failed to show that oxygen therapy was being received during the lookback period. The facility also failed to document alarm use on the MDS for 6 residents who had active alarm-related orders. These residents had orders for bed alarms, chair alarms, floor alarms, bathroom door alarms, wheelchair alarms, or combinations of these devices, with diagnoses including dementia, Alzheimer's disease, gait abnormalities, repeated falls, and muscle weakness. The MDS assessments reviewed for these residents failed to reveal evidence that alarms were utilized, and the MDS Coordinator stated that alarm use should have been included when used during the lookback period but could not provide evidence that it was documented.
Missing Admission Assessment on Readmission
Penalty
Summary
The facility failed to ensure an admission assessment was completed for Resident #4 upon readmission. Record review showed the resident was discharged from the facility and transferred to the hospital, then later returned to the facility. The MDS data entry assessment dated 04/30/26 showed the resident had returned, but there was no comprehensive assessment completed for the readmission. During an interview on 05/20/26, the MDS Coordinator stated that Resident #4 should have had an admission assessment completed for readmission to the facility.
MDS assessments did not accurately capture psychotropic medications for two residents
Penalty
Summary
The facility failed to accurately complete the MDS for Resident 5 and Resident 27 during admission assessment. Resident 5 had diagnoses including major depressive disorder, and the 06/10/25 MDS documented a BIMS score of 14 and listed a diuretic, opioid, hypoglycemic, and anticonvulsant, but did not accurately document the antidepressant sertraline 50 mg that was ordered on 05/29/25 and administered daily from 06/04/25 through 06/10/25. Because the antidepressant was not accurately entered on the MDS, the Psychotropic Drug Use CAA was not triggered, and the CAA and care plan did not reflect the antidepressant at admission. Resident 5 was observed on 05/21/26 sitting in a recliner watching television and appeared relaxed and comfortable. Resident 27 had diagnoses including insomnia and major depressive disorder, and the 09/08/25 MDS documented a BIMS score of 14 and listed an antidepressant, anticoagulant, and opioid, but did not accurately document the hypnotic zolpidem 10 mg ordered on 09/02/25 and administered daily from 09/02/25 through 09/08/25. The Psychotropic Drug Use CAA documented pain medication management but did not include the hypnotic or the diagnosis of insomnia, and the care plan was not updated with the psychotropic use care plan for nurse documentation of behaviors and side effects. On 05/19/26, Resident 27 was observed reclined in a chair with her feet up, requested that her bed be switched out for the recliner, and stated that she stayed in her room and lay there all day.
Incomplete Assessment of Transfer Pole Use
Penalty
Summary
Resident 6 was not completely assessed for functional use of a transfer pole. The resident was admitted with paraplegia and had intact cognition with a BIMS score of 14. The medical record showed the resident used a transfer pole in bed, and the resident stated the poles helped with turning and during care because of paralysis from the waist down. The facility’s accident prevention care plan identified the use of a transfer pole, but the OT evaluation and plan of treatment and the PT evaluation and plan of treatment did not reflect the transfer pole, its benefit, clinical justification, or appropriateness for the resident's use. The interdisciplinary resident screen later documented no significant decline in ROM, mobility, or ADL performance and indicated skilled PT/OT services were not indicated, with continuation of the restorative nursing program. However, the restorative nursing order addressed only lower extremity PROM and did not show PROM exercises for the upper extremities. During interviews, the DOR stated PT or OT should have assessed transfer pole use and that it should have been documented on the rehab evaluation and screening. The MDS Coordinator stated she should have completed and documented that part of the assessment on the MultiCare Conference Assessment and care plan, and the DON acknowledged the findings.
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