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F0636
E

Failure to Timely Transmit MDS Assessments

Spring Lake, Michigan Survey Completed on 06-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to transmit Minimum Data Set (MDS) assessments in a timely manner for four residents. For one resident, the annual assessment with an assessment reference date (ARD) in March was not completed until June, resulting in a significant delay. Another resident's annual assessment, due in early May, was not completed until June as well. The MDS Coordinator/Registered Nurse confirmed that these assessments were over 120 days old and acknowledged that one assessment was missed entirely, while another was not flagged as due or late in the electronic medical record (EMR) system. Additionally, two other residents experienced delays in the completion and submission of their MDS assessments. One resident's 5-day assessment and admission assessment were flagged as overdue in the EMR, with the entry not signed off until several days after the ARD. Another resident's 5-day admission assessment was also submitted late, as confirmed by the MDS Coordinator. The Nursing Home Administrator was made aware of these late assessments by the MDS Coordinator.

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