Failure to Complete Timely Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for one resident within the required timeframe of 366 days from the previous assessment. Record review showed that the resident, who had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes mellitus, was admitted on a specified date and did not have a comprehensive MDS assessment completed after the last one documented. This was confirmed during an interview with the MDS Coordinator, who acknowledged that the required assessment had not been completed within the mandated period. Facility policy requires that comprehensive assessments be conducted according to the Resident Assessment Instrument (RAI) User Manual, with annual assessments completed at least every 366 days.
Plan Of Correction
Resident #22 was immediately assessed and found to have no adverse effects. All residents have the ability to be affected. MDS reviewed all residents for open annual MDS Assessments on 5/22/25 to ensure they were complete. Resident #22 annual MDS Assessments were immediately reviewed and completed on 5/29/25 by MDS. Admin immediately provided MDS Coordinator education on MDS Assessments policy and timely submission. DON/designee to audit 2 residents with annual MDS assessments due weekly for 4 weeks. Results to be reviewed in QAPI.