Failure to Timely Complete MDS Assessments After Significant Change
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe following a significant change in condition for five residents who enrolled in hospice care. For each resident, the Electronic Health Record and Medicare Hospice Election forms documented the date hospice services began, but the corresponding Significant Change MDS assessments were completed and dated well beyond the 14-day requirement outlined in the 2024 Resident Assessment Instrument (RAI) Manual. The delays ranged from 18 to 25 days after hospice election, exceeding the federal guidelines for timely assessment. This deficiency was identified through clinical record review and staff interviews, which confirmed that the facility did not have a policy regarding MDS Assessments and relied solely on the RAI manual. The residents involved were all documented as having a significant change in condition due to enrollment in hospice care, which should have triggered a timely comprehensive assessment. The lack of timely MDS completion was observed for all five residents reviewed for MDS Assessments.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with terminal Parkinson’s disease and severe cognitive impairment was enrolled in hospice, with hospice aides providing baths and an updated care plan specifying hospice CNA, RN, social services, and chaplain visits. However, no hospice physician order was present in the EHR at the time, no hospice notes appeared in progress notes, and the MDS still reflected that the resident was not on hospice. The MDS Coordinator reported she did not complete a Significant Change in Status Assessment because there was no hospice order in the system to trigger it, later finding that the hospice admission order had been dated earlier but not entered until much later. The DON stated that the nurse on duty at hospice admission should have entered the hospice order and believed nurses knew they were responsible for doing so.
A resident with severely impaired cognition, type 2 DM with neuropathy, and a history of a Stage 3 pressure ulcer experienced a documented decline in both skin condition and functional status. An MDS assessment early in the stay showed no pressure ulcers and a need for maximal assistance with several ADLs, while later skin assessments and weekly pressure injury records showed a persistent Stage 3 pressure ulcer to the buttock, and OT notes documented a change from minimal assist to total dependence for lower body dressing. Despite these changes not returning to baseline within two weeks, staff did not complete a Significant Change in Status Assessment (SCSA) MDS as required by the RAI guidelines.
Failure to complete a significant change assessment for major weight loss. A resident with no decision-making capacity lost over 18% of body weight in less than 3 months, with repeated wt declines documented and RD notes calling the loss significant and clinically significant. The care plan addressed nutrition and wt monitoring, but no significant change assessment was found in the record.
A resident with HTN, CKD, and dependence on renal dialysis had repeated nursing documentation of negative thrill and bruit, showing the AV fistula was not properly functioning. The DON verified that no change-of-condition assessment was completed and the MD was not notified, despite the expectation that licensed nursing staff report the change; the DON stated this placed the resident at risk of missing HD as scheduled.
A resident with a history of SAH, TBI, and HTN sustained a left shoulder dislocation, after which the care plan and MD orders were updated to include ER transfer, pain management, immobilization of the left upper extremity, and a restriction on RNA services to the affected shoulder. The PT and RNAs adjusted PROM to exclude the injured shoulder, continued PROM to the right upper extremity, and used two-person assistance with a sling and pillows for repositioning, while noting that the responsible party opposed upper arm PROM and showers. Despite these changes and the facility’s policy and RAI criteria requiring a Significant Change in Status Assessment (SCSA) when there is a major change affecting multiple health areas and necessitating IDT review and care plan revision, the MDS-C confirmed that no SCSA was completed for this resident.
A resident with chronic respiratory failure with hypoxia and dementia was started on hospice care per physician order and care plan documentation, but the facility did not complete the required significant change in condition/status MDS assessment within 14 days of this change. The MDS coordinator and CNO both acknowledged that the significant change MDS should have been completed but was not, resulting in the resident’s status not being accurately reflected in the assessment.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days of a resident’s hospice service election, as required by the CMS RAI Manual. The resident had a terminal prognosis related to Parkinson’s disease and a quarterly MDS dated 02/20/2026 showed severe cognitive impairment (BIMS score of 4) and no hospice services. The care plan, reviewed on 03/16/2026 and revised on 04/07/2025, was updated with an intervention initiated on 04/20/2026 indicating that a named hospice provider would supply a CNA up to five times weekly, an RN weekly and PRN, social services monthly and PRN, and chaplain services monthly and PRN, with a contact number listed. A CNA reported that the resident’s baths were being provided by hospice aides who visited about three days a week. Record review showed no physician’s order for hospice services in the electronic health record at the time of survey, and progress notes from 03/01/2026 through 04/24/2026 contained no hospice notes. During interview, the MDS Coordinator stated she completes all MDS assessments and had not done a significant change MDS for this resident’s hospice admission because there was no physician’s order in the system to alert her. Upon review, she identified that an order to admit the resident to hospice services was dated 03/24/2026 but was not entered into the system until 04/23/2026, and acknowledged that the ARD should have been set within 14 days of hospice election, by 04/07/2026. The DON stated that the nurse on duty when the resident was admitted to hospice should have entered an admission order for hospice and expressed that she believed nurses understood they were responsible for adding such orders, treating them like any other order.
Failure to Complete SCSA MDS After Resident’s Decline in Skin and Functional Status
Penalty
Summary
Facility staff failed to complete a Significant Change in Status Assessment (SCSA) MDS for a resident who experienced a notable decline in skin condition and functional status that did not return to baseline within two weeks. The resident was originally admitted on 1/20/2026 and later readmitted with diagnoses including thoracic intervertebral disc degeneration, a Stage 3 pressure ulcer to the left buttock, and type 2 DM with diabetic neuropathy. An MDS dated 1/23/2026 documented severely impaired cognition, no pressure ulcers/injuries, and a need for maximal assistance with toileting hygiene, tub/shower transfers, lower body dressing, sit-to-lying, and lying-to-sitting on the side of the bed. Subsequent skin and body assessments and weekly pressure injury records dated in March and April 2026 showed the presence and continued existence of a Stage 3 pressure ulcer to the left buttock, which differed from the earlier MDS documentation of no pressure ulcer. In addition to the skin changes, an OT Therapy Progress Report covering services from 4/1/2026 through 4/7/2026 documented a decline in the resident’s functional status for lower body dressing. The report indicated that the prior level of function for lower body dressing was minimal assist, while the baseline, previous, and current status all reflected total dependence with attempts to initiate. According to the RAI Manual, Chapter 2, an SCSA must be completed when the IDT determines that a resident has a significant change in condition from baseline that is not expected to return to baseline within two weeks. Despite the documented decline in both skin condition and functional status compared to the most recent comprehensive assessment, the facility did not complete the required SCSA MDS for this resident.
Failure to Complete Significant Change Assessment for Major Weight Loss
Penalty
Summary
The facility failed to perform a comprehensive assessment after a significant change in condition for a resident who experienced substantial weight loss. Resident #9 was admitted weighing 228.6 lbs and later weighed 186.4 lbs, reflecting an 18.46% loss in less than three months. The resident did not have capacity to make his own medical decisions. His diet orders included a regular diet with regular texture and thin liquids, along with fortified food at lunch and supplements for wound healing and general support. The record showed a nutritional risk assessment completed shortly after admission that documented normal nutritional status, despite noting obesity, excellent meal intake, and a plan to monitor weights, intake, hydration, labs, and skin integrity. The care plan identified the resident as at risk for malnutrition and included goals related to gradual weight loss and maintaining nutritional status. Subsequent weights showed continued decline, including a 9.5% loss in one month and a 16.18% loss since admission, and dietitian notes described the loss as significant and clinically significant while stating the MD was aware. A later note stated the resident triggered for unplanned significant weight loss and that fortified food was recommended, but the medical record contained no significant change assessment related to the weight loss.
Failure to Assess and Report Nonfunctioning AV Fistula
Penalty
Summary
The facility failed to assess a significant change in condition and notify the physician when Resident 1’s AV fistula was not properly functioning. Resident 1 was admitted with diagnoses that included hypertension, chronic kidney disease, and dependence on renal dialysis. During review of the record, licensed nursing staff documented negative thrill and bruit on 3/14, 3/24, 3/25, 3/26, 3/27, 3/28, and 3/31, indicating the AV fistula was not functioning as expected. During a concurrent interview and record review with the DON, it was verified that a change of condition assessment was not completed and the physician was not informed of the negative thrill and bruit findings. The DON stated it was her expectation that licensed nursing staff notify the MD of the change in condition, and stated this placed Resident 1 at risk of missing hemodialysis as scheduled.
Failure to Complete SCSA After Resident Shoulder Dislocation
Penalty
Summary
The deficiency involves the facility’s failure to complete and document a Significant Change in Status Assessment (SCSA) for a resident who experienced a left shoulder dislocation. The resident had been admitted with diagnoses including subarachnoid hemorrhage, traumatic brain injury, and hypertension. On the date of the shoulder dislocation, the care plan was updated with a new focus that the resident had a dislocated left shoulder, with goals and interventions such as sending the resident to the ER, administering pain medication, immobilizing the left upper extremity, and monitoring for pain and swelling. A physician order was entered indicating no Restorative Nursing Aide (RNA) services to the left shoulder until further notice. During interviews and record reviews, the PT and RNAs reported that the resident previously had upper and lower extremity PROM ordered, which was later changed to lower extremity PROM only due to the left shoulder dislocation. They also stated that PROM was still provided to the right upper extremity, that the resident’s responsible party did not want upper arm PROM or showers because of the shoulder dislocation, and that the resident required two-person assistance for repositioning using a sling and pillows or rolled towels to support the left arm. The PT and RNAs indicated they did not participate in the resident’s IDT meetings but held separate therapy plan of care meetings, with the MDS Coordinator setting up those meetings and documenting notes in the EMR. When the DON, SSD, and Subacute ADON reviewed the EMR, the DON indicated she needed to verify whether an SCSA had been completed. In a subsequent review with the MDS Coordinator, it was confirmed that no SCSA had been completed for the shoulder dislocation. The MDS Coordinator described the RAI definition and criteria for an SCSA, acknowledged that the resident’s condition met the significant change criteria, and stated that the facility policy, which requires an SCSA when there is a major decline or improvement affecting more than one area of health status and requiring IDT review and care plan revision, had not been followed. Facility policies on RAI assessments and baseline care plans specified that assessments are ongoing, care plans must be reviewed and revised with changes in condition, and the IDT is responsible for evaluating and updating care plans when there has been a significant change, but this process was not carried out for the resident’s left shoulder dislocation.
Failure to Complete Significant Change MDS After Initiation of Hospice Care
Penalty
Summary
The facility failed to complete a significant change in condition or status assessment MDS within 14 days after a resident began hospice care, resulting in an inaccurate reflection of the resident’s status. The resident was admitted with multiple diagnoses, including chronic respiratory failure with hypoxia and dementia. A physician order dated 2/19/26 documented end-of-life care with hospice services, and the resident’s care plan also documented that hospice care started on that date. Despite this documented change in condition and care approach, the facility did not complete the required significant change MDS assessment within the mandated timeframe. On 3/31/26, the MDS coordinator acknowledged that the significant change assessment had not been completed and stated it should have been. On 4/1/26, the CNO similarly stated that the significant change in condition or status assessment MDS should have been completed within 14 days of the start of hospice care and had not been. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments.
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