F0638

D

Failure to Complete Required Quarterly MDS Assessment on Time

Tulsa, Oklahoma Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to complete a required quarterly MDS assessment within the mandated timeframe for one resident. Facility policy titled "MDS 3.0 Completion" required that quarterly comprehensive assessments be completed no greater than 92 days from the resident’s last quarterly assessment. Record review showed that a resident with diagnoses including parkinsonism and diabetes mellitus had a quarterly assessment dated 11/18/25, and the facility’s comprehensive assessment list indicated the next quarterly assessment was due by 02/18/26 and was still listed as in progress after that date. On 03/05/26 at 7:55 a.m., the MDS coordinator confirmed that the resident’s quarterly assessment was due on 02/18/26 and acknowledged it should have been completed by that time.

This deficiency involved one of three sampled residents reviewed for quarterly assessments, in a facility with 52 residents, and was based on record review and staff interview demonstrating noncompliance with the facility’s own MDS completion policy and the required quarterly assessment schedule.