366360
04/18/2022
Vineyards at Concord, The
119 West High Street Frankfort, OH 45628
F 0638
Assure that each resident’s assessment is updated at least once every 3 months.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to complete required Minimum Data Set (MDS) assessments. This affected 10 (#1, #6, #9, #10, #12, #116, #117, #118, #164, and #166) of 17 residents reviewed for completed MDS assessments. The facility census was 23.
Residents Affected - Some
Findings include: 1. Record review for Resident #1 revealed no MDS assessments had been completed for the resident since the annual MDS assessment dated [DATE]. 2. Record review for Resident #6 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 3. Record review for Resident #9 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 4. Record review for Resident #10 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 5. Record review for Resident #12 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 6. Record review for Resident #116 revealed no MDS assessments had been completed for the resident since the admission MDS assessment dated [DATE]. 7. Record review for Resident #117 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 8. Record review for Resident #118 revealed no MDS assessments had been completed for the resident since the Medicare-30 Day/End of Therapy MDS assessment dated [DATE]. 9. Record review for Resident #164 revealed no MDS assessments had been completed for the resident since the annual MDS assessment dated [DATE]. 10. Record review for Resident #166 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE].
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366360
366360
04/18/2022
Vineyards at Concord, The
119 West High Street Frankfort, OH 45628
F 0638
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Interview with Facility Manager #5 on 04/13/22 at 1:30 P.M. verified MDS assessments had not been completed for Resident #1, #6, #9, #10, #12, #116, #117, #118, #164, and #166 due to facility staff not having time for which to do so. Review of the online Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI 3.0 User's Manual (https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf), dated 10/2019, revealed quarterly MDS assessments were to be completed within 92 days of the most recent annual or quarterly MDS assessment.
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366360
04/18/2022
Vineyards at Concord, The
119 West High Street Frankfort, OH 45628
F 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to timely complete and submit the Minimum Data Set (MDS) assessments. This affected eight (#1, #3, #4, #13, #116, #117, #164, and #166) of 17 residents reviewed for completed and submitted MDS assessments. The facility census was 23.
Residents Affected - Some
Findings include: 1. Record review for Resident #1 revealed the quarterly MDS assessment, dated 12/10/21, was in in progress and had not been submitted. 2. Record review for Resident #3 revealed the quarterly MDS assessment, dated 02/06/22, was in progress and had not been submitted. 3. Record review for Resident #4 revealed the annual MDS assessment, dated 02/02/22, was in progress and had not been submitted 4. Record review for Resident #13 revealed the admission MDS assessment, dated 03/28/22, was in progress and had not been submitted. 5. Record review for Resident #116 revealed the entry MDS assessment, dated 12/17/21, and the admission MDS, dated [DATE], were in progress and had not been submitted. 6. Record review for Resident #117 revealed the quarterly MDS assessment, dated 11/11/21, was in progress and had not been submitted. 7. Record review for Resident #164 revealed the annual MDS assessment, dated 11/10/21, was in progress and had not been submitted. 8. Record review for Resident #166 revealed the quarterly MDS assessment, dated 12/10/21, was in progress and had not been submitted. Interview on 04/13/22 at 1:30 P.M. with Facility Manager #5 verified the MDS assessments had not been completed or submitted for Resident #1, #3, #4, #13, #116, #117, #164, and #166 due to facility staff not having enough time for which to do so. Review of the online Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI 3.0 User's Manual (https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf), dated 10/2019, revealed MDS assessments should be completed and submitted no later than 14 days after the assessment was initiated.
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