Failure to Complete MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed and signed as required within 14 days of the Assessment Reference Date (ARD) for two residents. According to facility policy and the CMS RAI 3.0 User's Manual, comprehensive assessments must be completed and signed within the specified timeframe. However, for one resident with a history of chronic obstructive pulmonary disease, adult failure to thrive, dementia, and disorientation, the annual MDS assessment with an ARD of 03/26/2025 was still marked as 'In Progress' at the time of the survey, with several sections incomplete and the assessment not signed as complete. Another resident, who had diagnoses including Parkinson's disease, restless leg syndrome, and schizoaffective disorder, had an annual MDS assessment with an ARD of 02/27/2025 that was not signed as complete until 04/25/2025, which exceeded the 14-day requirement. Interviews with the MDS Manager, MDS Assistant, and DON revealed that the MDS department was behind on assessments, with staff acknowledging delays and ongoing efforts to catch up. The MDS Assistant reported using a spreadsheet to track due dates, but assessments from previous months remained incomplete at the time of the survey. The Administrator confirmed that timely completion of MDS assessments was expected and acknowledged challenges within the MDS department. The DON and MDS staff indicated that staffing changes and inexperience contributed to the delays, and that part-time staff were being utilized to assist with the backlog. Despite these efforts, the required MDS assessments for the two residents were not completed within the mandated timeframe, resulting in noncompliance with federal requirements.