Quarterly MDS Assessment Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to complete and sign the federally mandated Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, the quarterly MDS must be completed and signed no later than 14 days from the assessment reference date. Record review showed that for one resident, the quarterly MDS with a reference date of 6/10/25 was not signed as completed as of 6/26/25, which was two days past the required deadline. During an interview, the MDS Coordinator, who had recently started in the role, stated that regional MDS support was responsible for signing the MDS as completed, but confirmed that the assessment had not been signed by the required date.