Failure to Complete Significant Change MDS After Self-Harm Incident
Summary
The facility failed to complete a Significant Change MDS assessment within 14 days after it determined, or should have determined, that Resident #2 had a significant change in physical or mental condition following a self-injury incident. Resident #2 was admitted and re-admitted to the facility with diagnoses including dementia, mild cognitive impairment, major depressive disorder, generalized anxiety disorder, bipolar disorder, and insomnia. Her quarterly MDS reflected a BIMS score of 15, independent self-care and mobility, and active psychiatric diagnoses with antipsychotic, antianxiety, and antidepressant medications. The record showed that on 9/16/2025, the DON was informed by the talk therapist that Resident #2 had disclosed wanting to harm herself and had reported drinking a bottle of eye drops the day before. Resident #2 confirmed that she drank a half bottle of over-the-counter eye drops because she was struggling with her bipolar disorder. The DON assessed her as alert and oriented to her situation, noted nausea and vomiting after the ingestion, and sent her to the ER for evaluation. The hospital encounter documented a high suicide risk assessment. Subsequent psychiatric follow-up documented severe anxiety, depression, and guilt feelings, and continued monitoring for recent suicidal ideation. The facility record reflected that no significant change in status assessment or interdisciplinary review was completed after the self-inflicting injury/self-harm incident, which was described as a major deviation from Resident #2's established baseline health. The MDS Coordinator stated she did not believe the event met criteria for a significant change in status because the resident was deemed safe by psychiatry and the hospital, and she viewed it as a one-off occurrence. The DON stated the incident was a significant change to the resident's baseline and that an RAI assessment should have been completed following the event. Facility policy stated that if a significant change in physical or mental condition occurs, a comprehensive assessment will be conducted as required by OBRA regulations and the MDS RAI manual.
Penalty
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The facility failed to complete an SCSA in a timely manner after a resident with COPD and chronic respiratory failure was discharged from hospice. Staff interviews and record review showed the EHR continued to list the resident as receiving hospice services after hospice had ended, and the SCSA was not completed until weeks later, after surveyor inquiry.
Failure to Complete Significant Change MDS After Hospice Election: A resident with diagnoses including a femur fracture, disorientation, and atrial fibrillation was admitted to hospice with a primary diagnosis of senile degeneration of the brain. The facility did not complete the required significant change in status MDS within 14 days of hospice admission, and a later quarterly MDS instead coded hospice. The MDS nurse said the omission was due to confusion about the payment source, and the DON stated hospice admission required a significant change MDS within 14 days.
A resident with metabolic encephalopathy and dysphagia was admitted to hospice for a terminal CVA, but the facility did not complete a significant change condition MDS within 14 days of the hospice admission. The MDS/RN acknowledged the assessment was not done timely, and the DON stated the resident should have had a significant change MDS when hospice services began.
A resident with MS, dementia, and CKD began hospice care, but the facility did not complete a significant change MDS to reflect the hospice status. The DON confirmed the resident was admitted to hospice and that no significant change MDS was completed.
Failure to complete a SCSA after a resident with COPD, CHF, dysphagia, and a PEG tube experienced increased behaviors, significant weight loss, and a hospitalization for lethargy, hypernatremia, dehydration, AKI, and acute metabolic encephalopathy. The MDSC acknowledged the decline and said the SCSA should have been completed, while the DON stated it was expected when a significant decline was identified.
Failure to complete Significant Change MDS assessments for two residents. One resident with severe cognitive impairment and major functional decline progressed from walker-assisted mobility to wheelchair use and mechanical lift transfers, while staff stated the resident had not walked for months. Another resident with a BIMS of 13 sustained a fibular neck fracture after a fall, remained painful and non-weight bearing, and continued to require a mechanical lift for transfers, but no timely SCSA was set up after the change in status was determined.
Delayed SCSA After Hospice Discharge
Penalty
Summary
The facility failed to timely complete a comprehensive assessment after a significant change in status for one resident, including failure to complete a Significant Change in Status Assessment (SCSA) after discharge from hospice services. The resident had diagnoses including COPD and chronic respiratory failure, and the most recent MDS identified that the resident was receiving hospice services. Hospice services were discontinued, but the resident’s electronic health record continued to show hospice status on the resident profile and care plan after hospice had ended. During interviews, staff confirmed the resident had been discharged from hospice and that the record still reflected hospice services. The CM stated the record should have been updated to accurately reflect the resident’s current status and that the SCSA was completed only after surveyor inquiry. The DON stated hospice discharges required updates to the care plan and clinical record and confirmed an SCSA should have been completed following the hospice discharge. Facility MDS history showed the SCSA was not completed until approximately three weeks after the hospice discharge, and the facility’s MDS policy required staff to identify significant changes, notify interdisciplinary team members, and complete the Significant Change MDS according to RAI Manual timelines.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a significant change in status MDS assessment within the required 14-day period after Resident #11 was admitted to hospice services. Resident #11 was admitted to the facility with diagnoses including fracture of the left femur with routine healing, disorientation, and atrial fibrillation, and was later admitted to hospice with a primary hospice diagnosis of senile degeneration of the brain. A review of the MDS assessments showed that no significant change in status assessment was completed after the hospice election, and instead a quarterly MDS completed later coded hospice. During interview, the MDS Nurse stated that a significant change in status MDS should be completed within 14 days of hospice admission and reported that it was not completed for Resident #11 because of confusion about the payment source. The DON stated that hospice admission was considered a significant change in status and required a significant change MDS assessment within 14 days of the hospice admission date.
Failure to Complete Significant Change Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in condition assessment for Resident 123, who was admitted with diagnoses including metabolic encephalopathy and dysphagia and was able to make needs known and sometimes understand others. The resident was admitted to hospice on 12/26/2025 for a terminal diagnosis of cerebrovascular accident, and the record showed the resident received hospice services. However, a significant change condition MDS assessment was not completed within 14 days of the hospice admission. During interviews, the MDS/RN stated the assessment was not done timely after hospice admission, and the DON stated the resident should have had a significant change condition MDS when admitted to hospice and that this did not meet expectations.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change MDS within 14 days after a resident began hospice care. Record review showed the resident was admitted with diagnoses of MS, dementia, and CKD. The Hospice Election Form was dated 03/26/26 and showed hospice care began on 03/27/26, but the most recent MDS assessment indicated the resident was not on hospice. During an interview on 05/14/26 at 4:10 pm, the DON stated that the resident was admitted to hospice on 03/27/26 and did not have a significant change MDS to reflect hospice care.
Failure to Complete Significant Change Assessment After Major Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment for one of three sampled residents after the resident experienced a major decline in multiple areas of health status. The resident had diagnoses of COPD, CHF, dysphagia with a PEG tube, and the record showed increasing behavioral incidents, including one incident in January 2026, two in February 2026, and 12 incidents from 3/9/26 to 4/1/26. The resident also had a 7.3 lb weight loss in one month and was hospitalized for lethargy, hypernatremia, dehydration, acute kidney injury, and acute metabolic encephalopathy, requiring a four-day hospital stay and medical intervention. During interview and record review, the MDS Coordinator stated she was aware of the increased behaviors, weight loss, and hospitalization and said she should have completed a SCSA in April 2026. The DON stated the expectation was for the MDS Coordinator to complete a SCSA when the resident was identified to have a significant decline and submit it timely. The resident’s most current quarterly MDS, dated 3/12/26, still indicated only physical and verbal behavioral symptoms toward others 1 to 3 days and no weight loss within the past six months, despite the later documented decline.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for two residents after major changes in condition were documented in the clinical record. One resident had severe cognitive impairment on the MDS, with care plan revisions showing a change from requiring one staff assist with a walker for transfers and ambulation to requiring two staff with a mechanical sit-to-stand lift. The record also showed a progression from partial/moderate assistance with walking and use of a walker and wheelchair to no longer attempting walking and using only a wheelchair. Staff interviews indicated the resident did not walk and had not walked for months, but the restorative task had not been removed or addressed through a significant change assessment. A second resident had a BIMS score of 13 and diagnoses including viral hepatitis, diabetes mellitus, chronic pain syndrome, and cerebral infarction. After a fall in which the resident was lowered to the floor when the right knee gave out, the resident was found to have an acute non-displaced fracture of the fibular neck and was placed on non-weight bearing status until orthopedic follow-up. After the orthopedic visit, the resident was ordered weight bearing as tolerated, but progress notes documented continued significant pain, continued non-weight bearing behavior, and ongoing use of a mechanical lift for transfers with assistance from two staff members. The resident’s care plan was revised to place ambulation on hold, use a wheelchair, use a mechanical lift for transfers, and later allow a mechanical sit-to-stand lift per therapy recommendations. The MDS tracking page showed no Significant Change in Status MDS had been set up within 14 days after the change was determined. The DON acknowledged that a Significant Change in Status MDS should have been completed, and the ADON reported being told she could either change the quarterly MDS or open a new significant change assessment.
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