Failure to Complete Quarterly MDS Assessments on Time
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for 37 out of 79 residents reviewed. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual specifies that quarterly assessments must be completed within 14 days after the Assessment Reference Date (ARD), and these assessments are due every 92 days. However, the facility did not adhere to these guidelines, resulting in late completion of assessments for numerous residents. For instance, Resident 1 had an ARD of November 2, 2024, and the assessment was due by November 15, 2024, but it was completed 10 days late on November 25, 2024. Similarly, Resident 2 had two instances of late assessments, with one being seven days late and the other six days late. This pattern of delayed assessments was consistent across multiple residents, with delays ranging from two to eleven days past the required completion date. The Registered Nurse Assessment Coordinator (RNAC) and the Director of Nursing confirmed during an interview that the quarterly MDS assessments were not completed within the required timeframe. This deficiency was noted under the regulations 28 Pa. Code 211.5(f) Clinical Records and 28 Pa. Code 211.12(d)(5) Nursing Services, indicating a failure in maintaining timely and accurate clinical records as mandated by the state regulations.
Plan Of Correction
1. A quarterly Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. 2. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next quarterly MDS assessment for the in-house residents. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. 3. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting quarterly assessments by the Regional Clinical Reimbursement Specialist or a designee. 4. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' quarterly MDS assessments to ensure compliance with F638 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
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.
A resident with dysphagia and an order for a regular, easy-to-chew diet with thin liquids did not receive required quarterly nutritional assessments from the RD, who only documented assessments at admission and several months later, with no subsequent reviews. The resident reported being unable to eat spicy foods, relying on food brought from home, and not receiving help from dietary staff with food preferences, which the resident stated caused increased anxiety. A Dietary Aide stated they were unaware of the resident’s preferences until the RD recently updated the meal ticket, and the DON indicated the RD was expected to be proactive in meeting nutritional needs and quality of life, consistent with the facility’s dietitian job description.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
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.
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.
Failure to Complete Quarterly Nutritional Assessments and Address Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when the Registered Dietician (RD) did not complete required quarterly nutritional assessments. The resident was admitted with diagnoses including dysphagia and had an order for a regular, easy-to-chew diet with thin liquids. Record review showed that the RD completed nutritional assessments only at admission in March 2025 and again in July 2025, with no further quarterly assessments documented thereafter. During a telephone interview, the RD acknowledged that subsequent quarterly nutritional assessments were not done and stated that the expectation was for timely assessments to monitor caloric needs, adverse weight changes, and changes to the diet plan. During an observation and interview, the resident reported being unable to eat spicy foods, that food was being brought in from home, and that dietary staff had not assisted with food preference requests, which the resident stated led to increased anxiety. In a separate interview, the Dietary Aide reported being unaware of the resident’s food preferences until recently, when the RD updated the resident’s meal ticket information, and acknowledged the importance of communication with residents and among staff to ensure meals match resident preferences. The DON stated that the RD was expected to be proactive in meeting residents’ nutritional needs and quality of life. The facility’s dietitian job description required informative dietary progress notes, periodic visits to evaluate meal quality and resident likes and dislikes, encouragement of resident/family participation, assistance with care plan scheduling, use of care plans in daily dietary services, review of nurses’ notes to determine if care plans were followed, and review of resident complaints and grievances.
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