Failure to Complete Required CAAs for Multiple Residents’ Annual MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete required Care Area Assessments (CAAs) for multiple residents whose comprehensive Minimum Data Set (MDS) assessments triggered these areas. The facility had a census of 29 residents with 12 residents sampled, and record review showed that four residents’ annual MDS assessments had triggered multiple CAAs that were not completed. One resident’s annual MDS dated 09/28/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer/injury, and psychotropic drug use, but none of these CAAs were completed. Another resident’s annual MDS dated 10/07/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, behavioral symptoms, falls, pressure ulcer/injury, psychotropic drug use, and pain, which were also not completed. A third resident’s annual MDS dated 08/25/25 triggered CAAs for ADL Functional/Rehabilitation Potential, urinary incontinence and indwelling catheter, nutritional status, pressure ulcer/injury, physical restraints, and pain, but these CAAs were not completed. A fourth resident’s annual MDS dated 04/16/25 triggered CAAs for cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, mood state, falls, nutritional status, dental care, pressure ulcer/injury, psychotropic drug use, and pain, and these CAAs were likewise not completed. During an interview on 03/10/26 at 4:06 PM, an administrative nurse acknowledged that the CAAs for these residents were missed, stated that the CAAs should be filled out to more accurately trigger care plan interventions, and noted she was still learning how to complete MDS assessments. The facility’s undated MDS Accuracy Audits policy documented a commitment to ensuring the accuracy, timeliness, and completeness of all MDS assessments.
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