Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and transmitted to the State within the required 7-day timeframe for 7 out of 9 residents reviewed. Record review, staff interviews, and reference to the RAI manual revealed that multiple MDS assessments, including Admission, Quarterly, and Annual assessments, were either not completed or not transmitted on time. The Director of Nursing (DON) confirmed that the facility was behind in reporting assessments to CMS and offered no explanation for the delays. Specific examples included residents with diagnoses such as malnutrition, seizures, dementia, bipolar disorder, and diabetes mellitus, whose MDS assessments were overdue by periods ranging from 11 to 52 days. The failure to complete and transmit these assessments as required resulted in the potential for harm and inaccuracy in identifying and addressing residents' needs, as timely assessments are necessary for proper care planning and regulatory compliance.