Failure to complete suicide risk assessment for resident with moderately severe depression
Summary
The facility failed to comprehensively assess a resident with signs and symptoms of moderate depression after the resident scored 17 on the PHQ-9, which indicated moderately severe depression. The resident’s diagnoses included schizoaffective disorder, bipolar disorder, anxiety disorder, and insomnia. The admission MDS indicated the resident was cognitively intact, had moderate depression, and required assistance with activities of daily living, including substantial assistance with lower extremity dressing and care. The resident’s CAA for psychosocial well-being documented “yes” to little interest or pleasure in doing things, and the CAA for mood state documented “yes” to thoughts that the resident would be better off dead or hurting himself in some way. No further information was documented on the mood state CAA. During multiple observations, the resident was not seen out of the room, and the room door was either cracked open or closed while the resident sat in a wheelchair watching TV with the volume low. The resident’s electronic medical record lacked evidence that the facility comprehensively assessed the resident’s history of suicidal thoughts. The comprehensive care plan noted alteration in mood and behavior related to loss of independence, a history of suicidal thoughts, that talking with staff helped the resident, and agreement to see Associated Clinic of Psychology. However, the record lacked evidence that the resident was offered ACP services. The social worker stated the facility should have completed a suicide prevention assessment with a PHQ-9 score of 17 and could not find documentation that ACP had been offered. The DON also reviewed the record and stated the facility expected a suicide prevention assessment at that score and expected ACP to be offered to all residents on admission, but could not find documentation that it had been offered to this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete CAA Documentation for Comprehensive MDS Assessments: The facility failed to complete required CAA analysis of findings for multiple residents after comprehensive MDS assessments. Missing CAA documentation involved triggered areas such as functional abilities, cognition, communication, falls, nutrition, dehydration, pressure injury, psychotropic drug use, urinary incontinence, pain, and psychosocial well-being. Survey staff confirmed the comprehensive MDSs were completed offsite by an RN, but the CAA records lacked source documentation and individualized analysis of the collected data.
Incomplete Quarterly MDS Assessment: A resident with COPD, depression, anxiety, rheumatoid arthritis, radiculopathy, spine fusion, and cognitive communication deficit had a Quarterly MDS with Sections B, C, D, and J left blank with dashes. The MDS Coordinator said the information was not in the chart and she did not try to obtain it herself; the ADON said she did not know about MDS assessments, and the Administrator stated staff should take measures to get needed information when possible.
A resident with stroke-related deficits, cognitive communication impairment, dysphagia, aphasia, schizoaffective disorder, and other chronic conditions did not have a comprehensive MDS completed within the required timeframe. The BIMS was handled as a Staff Assessment for Mental Status because the resident could not complete the interview, and multiple incomplete BIMS UDAs delayed completion of the MDS and the resident’s person-centered care plan. Interviews showed the MDS Case Manager, DOR, Administrator, and DON were aware of assessment workflow issues and missed deadlines.
The facility failed to complete required MDS assessments within the required timeframe for six residents. Review of records showed late admission and annual MDS completions, and the Regional Director of Operations confirmed the deficiency during interview.
Late Completion of MDS Assessments: The facility failed to complete multiple resident MDS assessments within the required 14-day ARD window. Admission, quarterly, annual, and 5-day assessments for numerous residents were completed late or remained incomplete, with delays ranging from a few days to more than a month. The MDS Nurse said she was behind because a coworker was on extended leave, and the DON and Regional Nurse said they were unaware the assessments were not being completed timely.
A resident’s annual MDS was coded incorrectly, leaving the Preferences for Customary Routine and Activities sections blank. The Regional Clinical Reimbursement Consultant stated the assessment was marked as if the facility were not Medicare or Medicaid certified, which prevented those sections from opening for completion. The Administrator stated staff were expected to code MDS assessments accurately.
Incomplete CAA Documentation for Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis of findings for multiple residents after comprehensive MDS assessments were completed. The report identified missing CAA completion for residents including R2, R3, R4, R7, R25, R48, R49, and R52, with triggered care areas such as communication, functional abilities, psychosocial well-being, behavioral symptoms, activities, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer/injury, psychotropic drug use, urinary incontinence/indwelling catheter, cognitive loss/delirium, pain, dental care, and visual function left without the required analysis of findings. During the survey, Administrative Nurse E stated she was not aware of a nurse at the facility who completed the MDS assessments and referred the inquiry to Administrative Nurse D. Administrative Nurse D said she thought the MDS assessments were completed offsite and referred the inquiry to Consultant II. Consultant II confirmed the comprehensive MDS assessments were completed off-site by an RN responsible for the accuracy and completion of the MDSs, including the comprehensive assessment with the analysis of findings/CAAs. Consultant KK stated the facility used the RAI Manual for guidance and confirmed the CAA documentation for the named residents lacked source documentation showing the analysis of the collected data, beyond the narrative identifying where the triggering information was located.
Incomplete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive, accurate, standardized, reproducible assessment for one resident on a Quarterly MDS assessment. The resident was an older male with diagnoses including COPD, limitation of activities due to disability, depressive episodes, anxiety disorder, rheumatoid arthritis, radiculopathy, fusion of spine, and cognitive communication deficit. Review of the Quarterly MDS showed that Hearing, Speech, Vision (Section B), Cognitive Patterns (Section C), Mood (Section D), and Health Conditions - Pain Assessment (Section J) were left blank with dashes instead of being completed. The resident’s comprehensive care plan, last revised on 6/30/26, included care plans for chronic pain, antidepressant medication use, mood problems related to suicidal ideations, depression, anxiety and insomnia, ineffective coping related to loss of a family member, risk for communication problems related to hearing deficit, risk for impaired visual function related to dry eyes, risk for impaired cognitive function/dementia or impaired thought processes related to cognitive defect, radiculopathy, and rheumatoid arthritis. In interview, the MDS Coordinator stated she completed the MDS assessments and said the sections were dashed out because the information was not in the chart; she also stated she did not attempt to obtain the information herself. The ADON said she did not know anything about MDS assessments, and the Administrator stated it was his expectation that staff should take measures to obtain needed information if there was a way to get it.
Delayed MDS Assessment and Incomplete BIMS Process
Penalty
Summary
The facility failed to complete a comprehensive MDS assessment within the required 14-day timeframe for a resident who had been admitted with multiple diagnoses, including cerebral infarction, cognitive communication deficit, dysphagia, anxiety disorder, flaccid hemiplegia affecting the right dominant side, malnutrition, dysarthria and aphasia, schizoaffective disorder, chronic venous insufficiency, hepatitis C, hyperlipidemia, seizures, hypertension, chronic embolism and thrombosis, GERD, and a history of heart-valve replacement. The resident’s comprehensive MDS assessment was initiated, but the ARD was set beyond the required assessment period and the assessment had not been completed within the regulatory timeframe. The BIMS portion of the resident’s MDS was completed as a Staff Assessment for Mental Status rather than a generalized BIMS interview. The assessment reflected that the resident had cognitive impairment and could not complete the BIMS interview, although he was able to recognize that he was in a nursing home and identify the location of his room. The record also showed multiple BIMS UDAs and incomplete assessment work, which delayed completion of the comprehensive MDS assessment and the resident’s comprehensive person-centered care plan. During interviews, the MDS Case Manager stated the comprehensive MDS assessment was required within 14 days of admission and confirmed the resident’s care plan was completed late because the MDS was delayed. The DOR stated she had been completing BIMS assessments and described her process for doing so, but also stated she was unsure about some reporting expectations when scores changed. The Administrator stated the DOR had reported feeling overwhelmed by the workload and that assessment deadlines were not being met. The DON stated she reviewed and signed MDS assessments but was unable to state the required timeframe for completion and did not understand why multiple BIMS UDAs were being completed in the manner observed. The facility policy required comprehensive RAI assessments to be completed within 14 days of admission and used to develop the resident’s comprehensive person-centered care plan.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments were completed within the required time frame for six of 24 residents. The RAI User's Manual dated October 2025 stated that an admission MDS assessment must be completed no later than 14 days after admission and that an annual MDS assessment must be completed no later than the ARD. Review of clinical records showed that Resident R3 was admitted on 4/20/26 and had an MDS completion date of 5/15/26; Resident R6 had an annual MDS ARD of 4/22/26 with completion on 5/13/26; Resident R15 had an annual MDS ARD of 4/2/26 with completion on 6/4/26; Resident R17 was admitted on 3/20/26 with MDS completion on 4/3/26; Resident R20 had an annual MDS ARD of 4/22/26 with completion on 5/13/26; and Resident R37 was admitted on 4/6/26 with MDS completion on 4/21/26. During an interview on 6/23/26, the Regional Director of Operations confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for these residents.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive MDS assessments were completed within 14 days of the ARD for 18 of 22 sampled residents. The affected assessments included admission, quarterly, annual, and 5-day MDSs for residents #1, 3, 4, 8, 10, 11, 13, 14, 17, 18, 20, 22, 23, 24, 26, 27, 28, and 30. Several assessments were completed late, including some by 4 to 35 days after the due date, while others were still not completed as of the survey date. Examples included an admission MDS for one resident that remained incomplete 37 days late, quarterly MDSs that were overdue by 27 to 35 days, and annual or admission assessments completed 9 to 30 days late. Interview with the MDS Nurse on 6/23/26 at 2:22 PM confirmed that each resident MDS assessment is to be completed within 14 days of the ARD date, and she stated she was behind because a coworker was on extended leave and many MDSs were overdue. Interview with the DON and Regional Nurse on 6/23/26 at 3:10 PM confirmed MDS assessments are to be completed for each resident at least quarterly and signed off within 14 days of the ARD date, and they stated they were unaware the MDSs were not being completed timely. The facility policy dated 2/6/26 directed that all MDS assessments be completed using a comprehensive interdisciplinary approach, that the MDS Coordinator maintain the schedule and monitor due dates, and that resident assessments begin on the first day of admission and be completed no later than the fourteenth day after admission.
Incomplete Annual MDS Preferences Coding
Penalty
Summary
The facility failed to complete the annual Minimum Data Set (MDS) to address the preferences of 1 of 18 residents reviewed for MDS accuracy, Resident #45. Resident #45 was admitted to the facility on [DATE], and the annual MDS dated [DATE] documented the resident as cognitively intact. However, the Preferences for Customary Routine and Activities sections were left incomplete and contained no information. The MDS nurse who completed the annual MDS was not available for interview. During an interview, the Regional Clinical Reimbursement Consultant stated the annual MDS for Resident #45 was coded incorrectly because it was marked as if the facility were not Medicare or Medicaid certified, which prevented the Preferences for Customary Routine and Activities section from opening for completion. The Administrator stated she expected staff to code MDS assessments accurately.
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