Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for five residents. According to federal requirements, a quarterly MDS assessment must have its Assessment Reference Date (ARD) within 92 days of the most recent OBRA assessment, and the assessment must be completed no later than 14 days after the ARD. For five residents, the quarterly MDS assessments were either completed late or not completed at all. Specifically, two residents had their assessments completed 30 days after the ARD, one resident's assessment was completed 26 days late, and two residents' assessments had not been completed as of the date of the survey review. During the survey, the Regional Nurse confirmed that the assessments for these residents were not completed within the required 14-day period following the ARD. The report provides specific admission dates for each resident and details the extent of the delays or lack of completion for each assessment. The deficiency was identified through a review of MDS assessment records and staff interviews, which verified the failure to meet the mandated assessment timelines.