Failure to Complete and Submit Annual MDS Assessment
Penalty
Summary
The facility failed to complete and submit an annual Minimum Data Set (MDS) assessment for one resident as required by federal regulations and facility policy. The policy and CMS guidelines specify that an annual MDS must be completed at least every 366 days, with the assessment reference date (ARD) set within this timeframe and the MDS finalized no later than 14 days after the ARD. For the resident in question, who had a medical history including type 2 diabetes and chronic kidney disease, the annual MDS with an ARD of 03/05/2025 was not signed or dated to indicate completion, and it had not been submitted as of the time of the survey. Interviews with the MDS Coordinators confirmed that the assessment was overdue and had not been transmitted, which was acknowledged as not meeting the facility's expectations for timely completion. The DON and Executive Director both stated that their expectation was for all MDS assessments to be completed and submitted within the required timeframes, but this did not occur for the resident identified in the sample.