Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframe of 92 days for nine out of eleven residents reviewed. Record reviews showed that for each of these residents, the last quarterly or annual MDS assessment was not followed by a subsequent quarterly assessment as mandated. The residents affected had various diagnoses, including Parkinsonism, dementia, diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, hypertensive heart disease, hemiplegia, hemiparesis, chronic pain syndrome, Alzheimer's disease, degeneration of the nervous system due to alcohol, epilepsy, congestive heart failure, and asthma. Interviews with the MDS Coordinator confirmed that the required quarterly assessments were not completed for these residents within the specified timeframe. The deficiency was identified through both record review and staff interviews, with the facility census at 66 residents at the time of the survey. No evidence was found in the records to indicate that the quarterly MDS assessments were completed as required for the identified residents.
Plan Of Correction
Residents #11, 20, 21, 22, 26, 29, 41, 42, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 quarterly MDS assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29 quarterly assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. MDS reviewed all quarterly MDS assessments on 5/21/25. Admin provided the MDS Coordinator education on quarterly MDS assessment policy and timely submission. The DON/designee will audit 3 residents' charts weekly to ensure quarterly MDS assessments are submitted timely for 4 weeks. Results will be reviewed in QAPI.