Failure to Complete Timely Comprehensive Assessment and Care Plan
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, and preferences within the required 14-day timeframe after admission, as mandated by both facility policy and federal regulations. The Minimum Data Set (MDS) for the resident, who was admitted with diagnoses including delusional disorders and severe bilateral visual impairment (category 3 blindness), was due by 8/21/2025 but was not completed until 8/25/2025, four days late. The incomplete and delayed assessment resulted in the absence of a care plan addressing the resident's significant visual impairment. During the period before the assessment was completed, the resident expressed frustration with her care, stating that staff did not know how to address her needs. Staff interviews revealed uncertainty in managing the resident's care, particularly regarding her refusal of incontinence care, and the DON acknowledged that the lack of a timely and thorough assessment contributed to the failure to address all of the resident's needs. Review of facility policies confirmed the requirement for timely MDS completion and comprehensive assessment to inform care planning.