Failure to Complete Quarterly MDS Assessments Timely
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for four residents, as required. Clinical record review showed that the MDS assessments for these residents were completed several days to weeks after the designated Assessment Reference Dates (ARDs). Staff interviews revealed that the MDS Coordinator was unable to complete the assessments on time due to increased infection control responsibilities and did not request additional assistance. The Director of Nursing acknowledged the issue with timeliness and stated that assessments should be completed within the appropriate timeframe. Additionally, the facility did not have a policy in place to address MDS assessment procedures.