Failure to Timely Complete and Submit Annual MDS Assessment
Penalty
Summary
The facility failed to complete and submit an Annual Minimum Data Set (MDS) assessment for a resident within the required timeframe established by the Centers for Medicare & Medicaid Services (CMS). The resident in question had a history of Alzheimer's disease, chronic kidney disease, and dementia, and was originally admitted in 2021 and re-admitted in 2023. During a review, it was found that the most recent annual MDS assessment for this resident was dated but had not yet been submitted to CMS, with the MDS Assistant confirming that the assessment was still in progress and overdue for submission. Interviews with facility staff revealed that the delay in MDS submission was known, and the Director of Nursing acknowledged the existence of late assessments. The facility's policy requires that MDS assessments be conducted and submitted according to federal and state timelines, with the assessment coordinator or designee responsible for timely submission. The failure to submit the MDS assessment as required constituted a deficiency in adhering to regulatory requirements for resident assessment and care planning.