Failure to Complete Required Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a required quarterly Minimum Data Set (MDS) assessment for one resident, as mandated by federal regulations. Specifically, the resident was admitted in February 2023, and while an MDS assessment was submitted on 2/5/25, there was no evidence in the clinical record of any subsequent quarterly assessment being completed within the required 92-day timeframe. During an interview, the MDS Nurse confirmed that a quarterly assessment should have been completed in May 2025 but was not done, despite referencing the RAI Manual for assessment timeliness. This lapse resulted in the resident not being reviewed between comprehensive assessments, which is necessary to monitor critical indicators of gradual status change as specified in the quarterly assessment requirements.