Failure to Complete Required Quarterly Smoking Safety Assessments
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Late Quarterly MDS Assessment: A resident with kidney and ureter disorder and essential primary HTN had a Quarterly MDS that was not completed within the required 3-month interval. Record review showed the assessment was completed after the due timeframe, and the SS Director stated care plan conferences needed to occur every 3 months.
Late Quarterly MDS Assessment: The facility failed to complete a resident’s quarterly RAI/MDS within the required 92-day timeframe. The MDSC and CNO stated the last quarterly assessment was completed 100 days after the prior one, and the next quarterly assessment due was still not completed when reviewed. The resident had diagnoses including arthrogryposis and multiple congenital anomalies, and the facility policy required quarterly reviews at least every 92 days.
Quarterly MDS assessments were not completed on time for three residents. One resident had multiple chronic conditions including HF, CKD, DM2, AFib, epilepsy, chronic pain, OA, osteoporosis, obesity, and COPD with moderate cognitive impairment; another had PVD, AFib, HTN, osteoporosis, GERD, depression, dysphagia, insomnia, and a left AKA; and a third resident had COPD. The MDS nurse confirmed the overdue assessments and could not explain why they were not initiated or completed timely.
A resident with spinal stenosis, diabetes, anemia, and hypertension had an annual MDS completed showing no cognitive impairment, but no subsequent MDS was submitted within the required quarterly timeframe. The MDS LVN, who relied on the EHR-generated schedule, acknowledged missing the quarterly MDS that was due, while the DON confirmed the due date and could not explain the omission. The Executive Director, who reported weekly MDS audits, verified that the next assessment should have been completed but was not, contrary to facility policy requiring quarterly MDS completion within 92 days of the prior comprehensive assessment.
Late Quarterly MDS Assessments: The facility failed to complete required MDS assessments within CMS timeframes for two residents. One resident with schizophrenia had a quarterly MDS completed 23 days after the ARD, and another resident with anxiety and HTN had the next MDS completed 94 days after the prior assessment. The MDS RN and DON confirmed the assessments were late under the RAI Manual requirements.
Incomplete Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments thoroughly for two residents. One resident’s MDS had Section C, Section D, and Section GG items not assessed or dashed, and another resident’s MDS had Section C items not assessed. The MDS coordinator stated the facility’s transition from paper charts to EHR had poor implementation and staff training, and the facility lacked a good process to ensure MDS completion and documentation.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 1 residents reviewed for resident assessment. Resident 6 had diagnoses including disorder of the kidney and ureter and essential primary hypertension. On 4/6 at 11:26 A.M., the resident's clinical record was reviewed and the most recent Quarterly MDS assessment was found to be dated [DATE] but was not completed until 4/10/26. During an interview on 4/17/26 at 10:35 A.M., the Social Services Director stated care plan conferences needed to be done every 3 months. On 4/17/26 at 10:40 A.M., the Administrator provided the current Care Planning policy dated 2/2026, which stated the facility will discuss the care plan with the resident and/or representative at regularly scheduled care plan conferences, initially, at routine intervals, and after significant changes.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident 23’s quarterly RAI/MDS assessment was completed within the required 92-day timeframe following the prior assessment. Resident 23’s history and physical dated April 14, 2024, documented admission to the facility with diagnoses including arthrogryposis and multiple congenital anomalies. During interview and record review, the MDS Coordinator Nurse stated that quarterly assessments are her responsibility and that they are expected to be completed within 92 days of the prior quarterly assessment. During the review, the MDS Coordinator Nurse and the Chief Nursing Officer both stated that Resident 23’s last quarterly assessment was completed on January 5, 2026, which was 100 days from the previous assessment, and that the quarterly assessment due on April 7, 2026 had not been completed and was 8 days late. Review of the facility’s policy titled Minimum Data Set (MDS) Assessments, dated March 2024, showed that quarterly review assessments must be completed at least 92 days following the previous assessment of any type. The CNO stated that the policy was not followed.
Quarterly MDS Assessments Not Completed Timely
Penalty
Summary
The facility failed to complete quarterly MDS assessments for three of seventeen residents reviewed for comprehensive assessments. Resident #49 was admitted with diagnoses including heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, epilepsy, chronic pain, osteoarthritis, osteoporosis, obesity, and COPD, and had a BIMS score of 9 indicating moderate cognitive impairment. The record showed the last MDS had an ARD of 11/25/2025, and the MDS nurse confirmed that no quarterly MDS had been completed since that assessment date. Resident #61 was admitted with diagnoses including PVD, atrial fibrillation, hypertension, osteoporosis, hyperlipidemia, GERD, depression, dysphagia, insomnia, and a left above-knee amputation. The last MDS had an ARD of 12/05/2025, and the MDS nurse stated the resident was due for a quarterly MDS on 03/07/2026 but could not explain why it was not initiated. Resident #51, a female resident with COPD, had a quarterly MDS with an ARD of 03/06/2026 and a signed completion date of 04/13/2026; during interview, the MDS float nurse stated it should have been signed by 03/20/2026 and could not explain why the former MDS nurse did not complete it timely.
Overdue Quarterly MDS Assessment for One Resident
Penalty
Summary
The facility failed to complete a required quarterly MDS assessment within the mandated three-month timeframe for one resident. The resident was an adult female admitted with diagnoses including spinal stenosis, diabetes, anemia, and hypertension. Her most recent comprehensive/annual MDS assessment was completed on 12/04/2025 and showed no cognitive impairment, with a BIMS score of 14/15. Review of the electronic health record under the MDS tab showed no subsequent MDS assessment had been submitted after 12/04/2025, and the next quarterly MDS assessment, with an ARD due by 03/06/2026, was 22 days overdue at the time of review. In interviews, the MDS LVN stated he relied on the electronic health record schedule to complete residents’ MDS assessments and acknowledged that the quarterly MDS for this resident, due on 03/06/2026, had been missed. The DON confirmed that the MDS LVN was responsible for completing MDS assessments and that she reviewed them for accuracy, and she verified that the last MDS was the annual assessment on 12/04/2025 with the next one due in March 2026, but could not explain why it was not completed. The Executive Director stated that resident MDS assessments were audited weekly and, upon reviewing the record, confirmed that the annual MDS was completed on 12/04/2025 and that the next assessment should have been completed in March 2026. The facility’s policy on MDS 3.0 Completion, dated 2025, specified that quarterly assessments must be completed using an ARD no more than 92 days from the most recent prior quarterly or comprehensive assessment, which was not followed in this case.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Quarterly MDS assessments were completed within the required timeframes for two sampled residents. Resident 40 had diagnoses including schizophrenia. During interview and record review, the MDS RN stated the resident’s most recent MDS had an ARD of 2/23/26 but was completed on 4/1/26, which was 23 days late. The MDS Final Validation Report identified the assessment as late because the completion date was more than 14 days after the ARD, and the DON confirmed the facility was responsible for ensuring the completion date was within 14 days after the ARD. Resident 46 had diagnoses including anxiety and hypertension. The MDS RN stated the resident’s admission MDS was completed on 12/1/25 and the next MDS was not done until 3/5/26, which was late. The clinical record showed the admission MDS had an ARD of 12/1/25 and the following MDS had an ARD of 3/5/26, making it 94 days after the prior assessment. The MDS Final Validation Report identified the assessment as completed late, and the DON confirmed the facility was responsible for ensuring the next MDS was completed within 92 days after the previous assessment.
Incomplete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments were completed in a thorough manner for 2 of 5 residents reviewed for assessment accuracy. The CMS RAI 3.0 User’s Manual was cited as requiring the full RAI process, including the MDS, CAA, and utilization guidelines, and describing quarterly assessments as non-comprehensive assessments completed every 92 days to monitor changes in resident status. The report also noted that Section C is used to assess cognitive patterns and Section D is used to address mood distress and social isolation, with specific methods and instructions provided for accurate coding. For one resident, the quarterly MDS indicated that the Brief Interview for Mental Status or Staff Assessment for Mental Status in Section C was not assessed, Section D was not assessed in its entirety, and Section GG functional ability items such as self-care and mobility were not assessed or were dashed. For the second resident, the quarterly MDS indicated that Section C cognitive pattern items were not assessed. During interview, the infection control preventionist/MDS coordinator stated the facility had recently transitioned from paper charts to an EHR, did not have a good process in place to ensure MDS assessments were completed and documented during the transition, and had poor implementation and poor staff training, resulting in many MDS assessment areas being missed. The facility’s MDS Completion and Submission Timeframe policy identified the assessment coordinator or designee as responsible for submitting the MDS according to the RAI manual, but did not further describe the process for completing the MDS before submission.
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