Failure to Complete Timely MDS Admission Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the federally required timeframe for 11 out of 20 sampled residents. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, admission MDS assessments must be completed no later than the 14th calendar day after a resident's admission. However, documentation showed that for these 11 residents, the assessments were completed between 15 and 30 days after admission, or in some cases, not completed at all by the time of the survey. Specific examples include assessments completed 30, 27, 26, 22, 20, and 15 days after admission, and two residents whose assessments were still incomplete more than 20 days post-admission. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the assessments were not completed within the required timeframe. The MDS Coordinator acknowledged being behind on the assessments and confirmed that the required timelines were not met for the identified residents. The Director of Nursing also stated that admission MDS assessments should be completed within 14 days of admission, further confirming the deficiency.